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Martinez-Correa S, Morales-Tisnés T, De Leon-Benedetti LS, Lazarte-Rantes C, Otero HJ. Fluoroscopy in pediatric radiology: Review of current use and alternatives. Clin Imaging 2025; 121:110454. [PMID: 40107007 DOI: 10.1016/j.clinimag.2025.110454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2025] [Revised: 02/20/2025] [Accepted: 03/10/2025] [Indexed: 03/22/2025]
Abstract
Fluoroscopy has long been an essential imaging modality in pediatric radiology. However, concerns about radiation exposure in children and the need for on-site staff have led to a decline in its use and the exploration of alternative imaging techniques. Data from the Pediatric Health Information System and our institution show a decrease in fluoroscopic studies among pediatric inpatients, from 56,371 per year (2017-2020) to 46,973 per year (2020-2023). Alternative modalities such as endoscopy, ultrasound, and computed tomography demonstrate promise in assessing conditions of the respiratory, gastrointestinal, and urinary systems. Although fluoroscopy remains valuable in certain scenarios, these alternative imaging modalities offer advantages in terms of diagnostic accuracy, accessibility, costs, and reduced radiation exposure. However, the final choice of imaging technique should be based on careful consideration of the specific clinical context, patient factors, and available resources. In this review, we present institutional and national trends on the utilization of fluoroscopic studies over the past years, along with a side-by-side comparison of traditional fluoroscopic studies commonly performed in children and newer alternative modalities.
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Affiliation(s)
- Santiago Martinez-Correa
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, United States of America.
| | - Tatiana Morales-Tisnés
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Laura S De Leon-Benedetti
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
| | | | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, United States of America; Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
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Möller K, Saborio M, Gottschall H, Blaivas M, Borges AC, Morf S, Möller B, Dietrich CF. The Perception of the Diaphragm with Ultrasound: Always There Yet Overlooked? Life (Basel) 2025; 15:239. [PMID: 40003648 PMCID: PMC11857681 DOI: 10.3390/life15020239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2024] [Revised: 01/30/2025] [Accepted: 02/02/2025] [Indexed: 02/27/2025] Open
Abstract
Diaphragm ultrasound makes it possible to diagnose diaphragmatic atrophy and dysfunction. Important indications include unclear dyspnea; diaphragmatic elevation; assessment of diaphragm dysfunction in pulmonary, neuromuscular and neurovascular diseases; and in critically ill patients before noninvasive and mechanical ventilation and follow-up of diaphragm thickness and function during mechanical ventilation with potential prediction of prolonged weaning. In patients with respiratory insufficiency and potential diaphragm dysfunction, it is possible to objectify the contribution of diaphragm dysfunction. In addition, assessment of diaphragmatic hernias, tumors and diaphragmatic dysfunction in COVID-19 and diaphragmatic ultrasound in sports medicine have been described. This narrative review includes the sonomorphology of the diaphragm, standardization of ultrasonographic investigation with transducer positions and ultrasound techniques, normal findings and diagnostic criteria for pathological findings. The correct sonographic measurement, calculation and evaluation can ultimately influence further therapeutic procedures for the patient suffering from diaphragm dysfunction in various diseases.
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Affiliation(s)
- Kathleen Möller
- Medical Department I/Gastroenterology, SANA Hospital Lichtenberg, 10365 Berlin, Germany (H.G.)
| | - Max Saborio
- Department General Internal Medicine (DAIM), Hospitals Hirslanden Bern Beau Site, Salem and Permanence, 3013 Bern, Switzerland;
| | - Heike Gottschall
- Medical Department I/Gastroenterology, SANA Hospital Lichtenberg, 10365 Berlin, Germany (H.G.)
| | - Michael Blaivas
- Department of Internal Medicine, School of Medicine, University of South Carolina, Columbia, SC 29209, USA;
| | - Adrian C. Borges
- Medical Department II/Cardiology, SANA Hospital Lichtenberg, 10365 Berlin, Germany;
| | - Susanne Morf
- Center da Sandà Val Müstair, 7536 Sta. Maria, Switzerland;
| | - Burkhard Möller
- Department of Rheumatology and Immunology, Bern University Hospital, Inselspital, University of Bern, 3010 Bern, Switzerland;
| | - Christoph F. Dietrich
- Department General Internal Medicine (DAIM), Hospitals Hirslanden Bern Beau Site, Salem and Permanence, 3013 Bern, Switzerland;
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Wang J, Liu F, Zhou M, Li D, Huang M, Guo S, Hou D, Luo J, Song Z, Wang Y. Effect of five different body positions on lung function in stroke patients with tracheotomy. Top Stroke Rehabil 2024:1-11. [PMID: 39460942 DOI: 10.1080/10749357.2024.2420545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 10/20/2024] [Indexed: 10/28/2024]
Abstract
BACKGROUND In stroke patients with tracheotomy, reduced lung function heightens pulmonary infection risk. Body position can affect lung function; however, its impact in stroke patients with tracheostomy remains unclear. OBJECTIVE To investigate the influence of five body positions on pulmonary function in stroke patients with tracheotomy. METHODS Pulmonary function was assessed in five body positions (supine, supine 30°, supine 60°, sitting, and prone) in 47 stroke patients who underwent tracheotomy. Diaphragmatic excursion during quiet breathing (DEQ), diaphragmatic thickening fraction during quiet breathing (DTFQ), and diaphragmatic excursion during coughing (DEC) were measured using ultrasound. Peak cough flow (PCF) was measured using an electronic peak flow meter. RESULTS Different positions had a significant impact on DEQ, DEC, and PCF in stroke patients with tracheotomy, although not on DTFQ. DEQ showed no significant differences between supine 60°, sitting, and prone positions. Both DEC and PCF reached their maximum values in the sitting position. In the sub-group analysis, DEQ in females did not show significant differences across different positions. Both males and females exhibited significantly higher PCF in the sitting compared to supine position. The lung function of obese patients was significantly better in the sitting than in the supine and supine 30° position. Regardless of the patient's level of consciousness and whether the brainstem was injured, lung function in the sitting position was significantly higher than in the supine position. CONCLUSIONS Body posture influences lung function in stroke patients with tracheotomy. Patients should adopt a sitting position to enhance pulmonary function.
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Affiliation(s)
- Juan Wang
- Children's Rehabilitation Department, Peking University First Hospital Ningxia Women and Children's Hospital (Ningxia Hui Autonomous Region Maternal and Child Health Hospital), Yinchuan, China
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Shenzhen University/Shenzhen Second People's Hospital, Shenzhen, China
| | - Fang Liu
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Shenzhen University/Shenzhen Second People's Hospital, Shenzhen, China
| | - Mingchao Zhou
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Shenzhen University/Shenzhen Second People's Hospital, Shenzhen, China
| | - Dan Li
- Department of Rehabilitation Medicine, The 940th Hospital of the Joint Logistic Support Force of the Chinese People's Liberation Army, Lanzhou, China
| | - Meiling Huang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Shenzhen University/Shenzhen Second People's Hospital, Shenzhen, China
| | - Shanshan Guo
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Shenzhen University/Shenzhen Second People's Hospital, Shenzhen, China
| | - Dianrui Hou
- Department of Rehabilitation Medicine, Shenzhen Dapeng New District Nanao People's Hospital, Shenzhen, China
| | - Jiao Luo
- Department of Rehabilitation Medicine, Shenzhen Dapeng New District Nanao People's Hospital, Shenzhen, China
| | - Zhenhua Song
- Department of Rehabilitation Medicine, The Haikou Hospital Affiliated to Xiangya Medical College of Central South University, Haikou, China
| | - Yulong Wang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Shenzhen University/Shenzhen Second People's Hospital, Shenzhen, China
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Yu Q, Song J, Yang L, Miao Y, Xie L, Ma X, Xie P, Chen S. A scoping review of preclinical intensive care unit-acquired weakness models. Front Physiol 2024; 15:1423567. [PMID: 39416383 PMCID: PMC11480018 DOI: 10.3389/fphys.2024.1423567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 09/23/2024] [Indexed: 10/19/2024] Open
Abstract
Background Animal models focusing on neuromuscular outcomes are crucial for understanding the mechanisms of intensive care unit-acquired weakness (ICU-AW) and exploring potential innovative prevention and treatment strategies. Aim To analyse and evaluate preclinical ICU-AW models. Methods We manually searched five English and four Chinese databases from 1 January 2002, to 1 February 2024, and reviewed related study references. Full-text publications describing animal models of muscle weakness and atrophy in critical illness were included. Detailed information about model types, animal species, sex, age, induction methods, outcome measures, drawbacks and strengths was extracted from each included study. Results A total of 3,451 citations were initially retrieved, with 84 studies included in the final analysis. The most frequently studied animal model included rodents (86.9%), 64.3% of which were male animals. ICU-AW animal models were mostly induced by comprehensive intensive care unit (ICU) interventions (38.1%) and sepsis (51.2%). Most studies focused on limb muscles (66.7%), diaphragm muscles (21.4%) or both (9.5%). Reported outcomes primarily included muscular pathological changes (83.3%), electrophysiological examinations of muscles (57.1%) and animal grip strength (16.6%). However, details such as animal age, mortality data, experimental design, randomisation, blinding, sample size and interventions for the experimental group and/or control group were inadequately reported. Conclusion Many preclinical models are used to study ICU-AW, but the reporting of methodological details is often incomplete. Although current ICU animal models can mimic the characteristics of human ICU-AW, there is no standard model. Future preclinical studies should develop a standard ICU-AW animal model to enhance reproducibility and improve scientific rigor in exploring the mechanisms and potential treatment of ICU-AW.
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Affiliation(s)
- Qingmei Yu
- Nursing Department, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
- School of Nursing, Zunyi Medical University, Zunyi, Guizhou, China
| | - Jiamei Song
- Nursing Department, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
- School of Nursing, Zunyi Medical University, Zunyi, Guizhou, China
| | - Luying Yang
- School of Nursing, Zunyi Medical University, Zunyi, Guizhou, China
- Department of Critical Care Medicine, The Third Affiliated Hospital of Zunyi Medical University, The First People’s Hospital of Zunyi City, Zunyi, Guizhou, China
| | - Yanmei Miao
- School of Nursing, Zunyi Medical University, Zunyi, Guizhou, China
- Department of Critical Care Medicine, The Third Affiliated Hospital of Zunyi Medical University, The First People’s Hospital of Zunyi City, Zunyi, Guizhou, China
| | - Leiyu Xie
- Department of Critical Care Medicine, The Third Affiliated Hospital of Zunyi Medical University, The First People’s Hospital of Zunyi City, Zunyi, Guizhou, China
| | - Xinglong Ma
- Department of Critical Care Medicine, The Third Affiliated Hospital of Zunyi Medical University, The First People’s Hospital of Zunyi City, Zunyi, Guizhou, China
| | - Peng Xie
- Department of Critical Care Medicine, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, China
| | - Shaolin Chen
- Nursing Department, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
- School of Nursing, Zunyi Medical University, Zunyi, Guizhou, China
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Peng L, Kang H, Chang H, Sun Y, Zhao Y, Zhao H. The ratio of parasternal intercostal muscle-thickening fraction-to-diaphragm thickening fraction for predicting weaning failure. J Crit Care 2024; 83:154847. [PMID: 38909540 DOI: 10.1016/j.jcrc.2024.154847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 05/22/2024] [Accepted: 06/14/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND Diaphragm dysfunction is associated with weaning outcomes in mechanical ventilation patients, in the case of diaphragm dysfunction, the accessory respiratory muscles would be recruited. The main purpose of this study is to explore the performance of parasternal intercostal muscle thickening fraction in relation to diaphragmatic thickening fraction ratio (TFic1/TFdi2) for predicting weaning outcomes, and compare its accuracy with D-RSBI in predicting weaning failure. MATERIALS AND METHODS We prospectively enrolled consecutive patients from 7/2022-5/2023. We measured TFic, TFdi, and diaphragmatic excursion (DE3) by ultrasound and calculated the TFic/TFdi ratio and diaphragmatic rapid shallow breathing index (D-RSBI4). Receiver-operator characteristic (ROC5) curves evaluated the accuracy of the TFic/TFdi ratio and D-RSBI in predicting weaning failure. RESULTS 161 were included in the final analysis, 114 patients (70.8%) were successfully weaned from mechanical ventilation. The TFic/TFdi ratio (AUROC = 0.887 (95% CI: 0.821-0.953)) was superior to the D-RSBI (AUROC = 0.875 (95% CI: 0.807-0.944)) for predicting weaning failure. CONCLUSIONS The TFic/TFdi ratio predicted weaning failure with high accuracy and outperformed the D-RSBI.
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Affiliation(s)
- Li Peng
- Department of Critical Care Medicine, Hebei Medical University, Shijiazhuang 050000, Hebei, China; Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang 050000, Hebei, China; Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Hongshan Kang
- Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Hairong Chang
- Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Yue Sun
- Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Yuanyuan Zhao
- Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Heling Zhao
- Department of Critical Care Medicine, Hebei Medical University, Shijiazhuang 050000, Hebei, China; Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang 050000, Hebei, China.
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Powers SK. Ventilator-induced diaphragm dysfunction: phenomenology and mechanism(s) of pathogenesis. J Physiol 2024; 602:4729-4752. [PMID: 39216087 DOI: 10.1113/jp283860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 08/12/2024] [Indexed: 09/04/2024] Open
Abstract
Mechanical ventilation (MV) is used to support ventilation and pulmonary gas exchange in patients during critical illness and surgery. Although MV is a life-saving intervention for patients in respiratory failure, an unintended side-effect of MV is the rapid development of diaphragmatic atrophy and contractile dysfunction. This MV-induced diaphragmatic weakness is labelled as 'ventilator-induced diaphragm dysfunction' (VIDD). VIDD is an important clinical problem because diaphragmatic weakness is a risk factor for the failure to wean patients from MV. Indeed, the inability to remove patients from ventilator support results in prolonged hospitalization and increased morbidity and mortality. The pathogenesis of VIDD has been extensively investigated, revealing that increased mitochondrial production of reactive oxygen species within diaphragm muscle fibres promotes a cascade of redox-regulated signalling events leading to both accelerated proteolysis and depressed protein synthesis. Together, these events promote the rapid development of diaphragmatic atrophy and contractile dysfunction. This review highlights the MV-induced changes in the structure/function of diaphragm muscle and discusses the cell-signalling mechanisms responsible for the pathogenesis of VIDD. This report concludes with a discussion of potential therapeutic opportunities to prevent VIDD and suggestions for future research in this exciting field.
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Affiliation(s)
- Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
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Liu C, He L, Zhang JH, He J, Tian L, Zheng X. Impact of high-protein enteral nutrition on muscle preservation in mechanically ventilated patients with severe pneumonia: a randomized controlled trial. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2024; 43:152. [PMID: 39342405 PMCID: PMC11439213 DOI: 10.1186/s41043-024-00633-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 08/26/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND This study aimed to assess the effects of enteral nutrition with different protein concentrations on muscle mass in severe pneumonia patients, providing insights for enteral nutrition practice in intensive care units (ICUs). METHODS A total of 120 severe pneumonia patients admitted to Dazhou Central Hospital's ICU between June 1, 2022, and February 1, 2023, meeting inclusion criteria, were randomly assigned to either a high-protein group (n = 60, 1.8 g/kg/d) or a standard-protein group (n = 60, 1.2 g/kg/d). Changes in relevant indicators were monitored on days 1, 5, and 10 of ICU admission, including quadriceps and diaphragm thickness, nutritional status (prealbumin and albumin), and adverse events such as diarrhea and constipation. RESULTS Autoregressive of order 1 model (AR(1)) analysis revealed a decrease in both quadriceps and diaphragm thickness over time in both groups. A significant group × time interaction was observed in quadriceps thickness. By day 10, compared to baseline, quadriceps thickness decreased in the high-protein (-0.315 cm [95% CI, -0.340 to -0.289]) and standard-protein (-0.429 cm [95% CI, -0.455 to -0.404]) groups. The high-protein group exhibited a lower quadriceps atrophy rate (13.97 ± 2.43%) compared to the standard-protein group (18.96 ± 2.61%), showing a significant difference (P < 0.001). No significant differences were found in diaphragmatic thickness between groups and over time. By day 10, both groups exhibited decreased diaphragmatic muscle thickness compared to baseline. The high-protein group (33.76 ± 5.09%) had a slightly lower phrenic atrophy rate compared to the standard-protein group (33.41 ± 4.53%). Both groups experienced enteral nutritional intolerance manifested as diarrhea, constipation, and other adverse events. CONCLUSION High-protein enteral nutrition significantly improved quadriceps thickness and demonstrated good safety in severe pneumonia patients, suggesting its suitability for widespread clinical application.
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Affiliation(s)
- Cheng Liu
- Department of Critical Care Medicine, The Central Hospital of Dazhou, Dazhou, 635000, Sichuan, China
| | - Li He
- Department of Critical Care Medicine, The Central Hospital of Dazhou, Dazhou, 635000, Sichuan, China
| | - Jin Hui Zhang
- Department of Critical Care Medicine, The Central Hospital of Dazhou, Dazhou, 635000, Sichuan, China
| | - JiangShan He
- Department of Critical Care Medicine, The Central Hospital of Dazhou, Dazhou, 635000, Sichuan, China
| | - Lin Tian
- Department of Critical Care Medicine, The Central Hospital of Dazhou, Dazhou, 635000, Sichuan, China
| | - Xiangde Zheng
- Department of Critical Care Medicine, The Central Hospital of Dazhou, Dazhou, 635000, Sichuan, China.
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Panelli A, Grimm AM, Krause S, Verfuß MA, Ulm B, Grunow JJ, Bartels HG, Carbon NM, Niederhauser T, Weber-Carstens S, Brochard L, Schaller SJ. Noninvasive Electromagnetic Phrenic Nerve Stimulation in Critically Ill Patients: A Feasibility Study. Chest 2024; 166:502-510. [PMID: 38403186 PMCID: PMC11443241 DOI: 10.1016/j.chest.2024.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Electromagnetic stimulation of the phrenic nerve induces diaphragm contractions, but no coils for clinical use have been available. We recently demonstrated the feasibility of ventilation using bilateral transcutaneous noninvasive electromagnetic phrenic nerve stimulation (NEPNS) before surgery in lung-healthy patients with healthy weight in a dose-dependent manner. RESEARCH QUESTION Is NEPNS feasible in critically ill patients in an ICU setting? STUDY DESIGN AND METHODS This feasibility nonrandomized controlled study aimed to enroll patients within 36 h of intubation who were expected to remain ventilated for ≥ 72 h. The intervention group received 15-min bilateral transcutaneous NEPNS bid, whereas the control group received standard care. If sufficient, NEPNS was used without pressure support to ventilate the patient; pressure support was added if necessary to ventilate the patient adequately. The primary outcome was feasibility, measured as time to find the optimal stimulation position. Further end points were sessions performed according to the protocol or allowing a next-day catch-up session and tidal volume achieved with stimulation reaching only 3 to 6 mL/kg ideal body weight (IBW). A secondary end point was expiratory diaphragm thickness measured with ultrasound from days 1 to 10 (or extubation). RESULTS The revised European Union regulation mandated reapproval of medical devices, prematurely halting the study. Eleven patients (five in the intervention group, six in the control group) were enrolled. The median time to find an adequate stimulation position was 23 s (interquartile range, 12-62 s). The intervention bid was executed in 87% of patients, and 92% of patients including a next-day catch-up session. Ventilation with 3 to 6 mL/kg IBW was achieved in 732 of 1,701 stimulations (43.0%) with stimulation only and in 2,511 of 4,036 stimulations (62.2%) with additional pressure support. A decrease in diaphragm thickness was prevented by bilateral NEPNS (P = .034) until day 10. INTERPRETATION Bilateral transcutaneous NEPNS was feasible in the ICU setting with the potential benefit of preventing diaphragm atrophy during mechanical ventilation. NEPNS ventilation effectiveness needs further assessment. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT05238753; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Alessandro Panelli
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany
| | - Aline M Grimm
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany
| | - Sven Krause
- Institute for Human Centered Engineering, Bern University of Applied Sciences, Biel/Bienne, Switzerland
| | - Michael A Verfuß
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany
| | - Bernhard Ulm
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Anesthesiology and Intensive Care, Munich, Germany; Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Ulm, Ulm, Germany
| | - Julius J Grunow
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany
| | - Hermann G Bartels
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany
| | - Niklas M Carbon
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany; Department of Anesthesiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Uniklinikum Erlangen, Erlangen, Germany
| | - Thomas Niederhauser
- Institute for Human Centered Engineering, Bern University of Applied Sciences, Biel/Bienne, Switzerland
| | - Steffen Weber-Carstens
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada; Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - Stefan J Schaller
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany; Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Anesthesiology and Intensive Care, Munich, Germany.
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Bentley I, Jocewicz FT, Johnson BD, Mehta HP. Evaluation of phrenic nerve stimulation trigger lag and synchronization in different modes of ventilation. Front Physiol 2024; 15:1397070. [PMID: 39015224 PMCID: PMC11250589 DOI: 10.3389/fphys.2024.1397070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 06/11/2024] [Indexed: 07/18/2024] Open
Abstract
Phrenic nerve stimulation is currently being investigated for the prevention of diaphragm atrophy in patients with mechanically supported breathing. Patients receiving breathing support from mechanical ventilation are at risk of mismatches between respiratory demand and ventilator support. Our objectives were to determine if a novel phrenic nerve stimulation device provided stimulation during inspiration as intended and did not exacerbate any potential discordances. A benchtop electromechanical simulation model was developed to validate phrenic nerve stimulation with simulated breathing. The phrenic nerve stimulation device was evaluated with a mechanical ventilator attached to a breathing simulator. The trigger ratio and time lag between phrenic nerve stimulation and mechanical ventilation was measured for multiple disease and ventilator parameters. For the 1:1 breath trigger ratio test, 99.79% of intended stimulation breaths received stimulation at the correct time. For the 1:4 breath trigger ratio test, 99.72% of intended stimulation breaths received stimulation at the correct time. For trigger lag times for the inspiratory and expiratory phases, the mean inspiratory lag was 36.10 ± 10.50 ms and 16.61 ± 3.61 ms, respectively. The following discordance scenarios were evaluated in conjunction with simulated phrenic nerve stimulation: asynchrony-false trigger, dyssynchrony-early trigger, dyssynchrony-late trigger, dyssynchrony-early cycling, dyssynchrony-late cycling. Testing demonstrated none of these discordances were exacerbated by the simulated phrenic nerve stimulation. The novel phrenic nerve stimulation device delivered electrical stimulation therapy as intended and did not exacerbate any simulated discordances.
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Sabetian G, Mackie M, Asmarian N, Banifatemi M, Schmidt GA, Masjedi M, Paydar S, Zand F. Ultrasonographic evaluation of diaphragm thickness and excursion: correlation with weaning success in trauma patients: prospective cohort study. J Anesth 2024; 38:354-363. [PMID: 38507058 DOI: 10.1007/s00540-024-03321-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 02/04/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE Prolonged mechanical ventilation (MV) subjects multiple trauma patients to ventilator-induced diaphragmatic dysfunction. There is limited evidence on the predictive role of diaphragm ultrasound (DUS) for weaning success in multiple trauma patients. Therefore, we evaluated Ultrasound of the diaphragm as a valuable indicator of weaning outcomes, in trauma patients. MATERIAL AND METHODS This prospective cohort study included 50 trauma patients from September 2018 to February 2019. DUS was performed twice: upon ICU admission and the first weaning attempt. The diagnostic accuracy of indexes was evaluated by ROC curves. RESULTS The study included patients with a mean age of 35.4 ± 17.37, and 78% being male. The median injury severity score was 75 (42-75). The failure group exhibited significantly lower right diaphragmatic excursion (DE) compared to the success group (P = 0.006). In addition, the failure group experienced a significant decrease in both right and left DE from admission to the first attempt of weaning from MV (P < 0.001). Both groups showed a significant decrease in inspiratory and expiratory thickness on both sides during weaning from MV compared to the admission time (P < 0.001). The findings from the ROC analysis indicated that the Rapid shallow breathing index (RSBI) (Sensitivity = 91.67, Specificity = 100), respiratory rate (RR)/DE (Right: Sensitivity = 87.5, Specificity = 92.31), and RR/TF (Thickening Fraction) (Right: Sensitivity = 83.33, Specificity = 80.77) demonstrated high sensitivity and specificity in predicting weaning outcome. CONCLUSION In the context of patients with multiple trauma, employing DUC and assessing diaphragmatic excursion, thickness, RR/DE index, RR/TF index, and RSBI can aid in determining successful ventilator weaning.
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Affiliation(s)
- Golnar Sabetian
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mandana Mackie
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Naeimehossadat Asmarian
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahsa Banifatemi
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Mansoor Masjedi
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shahram Paydar
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farid Zand
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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11
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Starkoff BE, Nickerson BS. Emergence of imaging technology beyond the clinical setting: Utilization of mobile health tools for at-home testing. Nutr Clin Pract 2024; 39:518-529. [PMID: 38591753 DOI: 10.1002/ncp.11151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 04/10/2024] Open
Abstract
Body composition assessment plays a pivotal role in understanding health, disease risk, and treatment efficacy. This narrative review explores two primary aspects: imaging techniques, namely ultrasound (US) and dual-energy x-ray absorptiometry (DXA), and the emergence of artificial intelligence (AI) and mobile health apps in telehealth for body composition. Although US is valuable for assessing subcutaneous fat and muscle thickness, DXA accurately quantifies bone mineral content, fat mass, and lean mass. Despite their effectiveness, accessibility and cost remain barriers to widespread adoption. The integration of AI-powered image analysis may help explain tissue differentiation, whereas mobile health apps offer real-time metabolic monitoring and personalized feedback. New apps such as MeThreeSixty and Made Health and Fitness offer the advantages of clinic-based imaging techniques from the comfort of home. These innovations hold the potential for individualizing strategies and interventions, optimizing clinical outcomes, and empowering informed decision-making for both healthcare professionals and patients/clients. Navigating the intricacies of these emerging tools, critically assessing their validity and reliability, and ensuring inclusivity across diverse populations and conditions will be crucial in harnessing their full potential. By integrating advancements in body composition assessment, healthcare can move beyond the limitations of traditional methods and deliver truly personalized, data-driven care to optimize well-being.
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Affiliation(s)
- Brooke E Starkoff
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Brett S Nickerson
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, USA
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12
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Ji HM, Won YH. Early Mobilization and Rehabilitation of Critically-Ill Patients. Tuberc Respir Dis (Seoul) 2024; 87:115-122. [PMID: 38228092 PMCID: PMC10990608 DOI: 10.4046/trd.2023.0144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/30/2023] [Accepted: 12/18/2023] [Indexed: 01/18/2024] Open
Abstract
Post-intensive care unit (ICU) syndrome may occur after ICU treatment and includes ICU-acquired weakness (ICU-AW), cognitive decline, and mental problems. ICU-AW is muscle weakness in patients treated in the ICU and is affected by the period of mechanical ventilation. Diaphragmatic weakness may also occur because of respiratory muscle unloading using mechanical ventilators. ICU-AW is an independent predictor of mortality and is associated with longer duration of mechanical ventilation and hospital stay. Diaphragm weakness is also associated with poor outcomes. Therefore, pulmonary rehabilitation with early mobilization and respiratory muscle training is necessary in the ICU after appropriate patient screening and evaluation and can improve ICU-related muscle weakness and functional deterioration.
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Affiliation(s)
- Hye Min Ji
- Veterans Medical Research Institute, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Yu Hui Won
- Department of Physical Medicine and Rehabilitation, Jeonbuk National University Medical School, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Jeonbuk National University–Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
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13
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Al-Husinat L, Jouryyeh B, Rawashdeh A, Robba C, Silva PL, Rocco PRM, Battaglini D. The Role of Ultrasonography in the Process of Weaning from Mechanical Ventilation in Critically Ill Patients. Diagnostics (Basel) 2024; 14:398. [PMID: 38396437 PMCID: PMC10888003 DOI: 10.3390/diagnostics14040398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/22/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
Weaning patients from mechanical ventilation (MV) is a complex process that may result in either success or failure. The use of ultrasound at the bedside to assess organs may help to identify the underlying mechanisms that could lead to weaning failure and enable proactive measures to minimize extubation failure. Moreover, ultrasound could be used to accurately identify pulmonary diseases, which may be responsive to respiratory physiotherapy, as well as monitor the effectiveness of physiotherapists' interventions. This article provides a comprehensive review of the role of ultrasonography during the weaning process in critically ill patients.
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Affiliation(s)
- Lou’i Al-Husinat
- Department of Clinical Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Basil Jouryyeh
- Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (B.J.); (A.R.)
| | - Ahlam Rawashdeh
- Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (B.J.); (A.R.)
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, 16132 Genova, Italy
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
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14
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Marques MR, Pereira JM, Paiva JA, de Casasola-Sánchez GG, Tung-Chen Y. Ultrasonography to Access Diaphragm Dysfunction and Predict the Success of Mechanical Ventilation Weaning in Critical Care: A Narrative Review. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:223-236. [PMID: 37915259 DOI: 10.1002/jum.16363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/09/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION Weaning failure is common in mechanically ventilated patients, and whether ultrasound (US) can predict weaning outcome remains controversial. This review aims to evaluate the diaphragmatic function measured by US as a predictor of weaning outcome. METHODS PubMed was searched to identify original articles about the use of diaphragmatic US in ICU patients. A total of 61 citations were retrieved initially; available data of 26 studies were included in this review. RESULTS To assess diaphragmatic dysfunction in adults, six studies evaluated excursion, five evaluated thickening fraction, and both in nine. Despite heterogeneity in the diagnostic accuracy of diaphragm US among the studies, the sonographic indices showed good diagnostic performance for predicting weaning outcome. CONCLUSIONS Diaphragmatic US can be a useful and accurate tool to detect diaphragmatic dysfunction in critically ill patients and predict weaning outcome.
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Affiliation(s)
- Marta Rafael Marques
- Department of Intensive Medicine, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - José Manuel Pereira
- Department of Intensive Medicine, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - José Artur Paiva
- Department of Intensive Medicine, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - Yale Tung-Chen
- Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
- Department of Medicine, Universidad Alfonso X, Villanueva de la Cañada, Madrid, Spain
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15
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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Dams K, De Meyer GR, Jacobs R, Schepens T, Perkisas S, Moorkens G, Jorens P. Combined ultrasound of m. quadriceps and diaphragm to determine the occurrence of sarcopenia and prolonged ventilation in a COVID-19 ICU cohort: The COVID-SARCUS trial. Nutrition 2024; 117:112250. [PMID: 37918311 DOI: 10.1016/j.nut.2023.112250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/29/2023] [Accepted: 09/27/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE The aim of this study was to determine the development of sarcopenia in a COVID-19 intensive care unit population by sequential quadriceps and diaphragm ultrasound and its relationship with hospital outcomes. METHODS We assessed muscle thickness, cross-sectional area, fascicle length, pennation angle, and echo intensity within 48 h after intubation, at days 5 and 10 and at discharge from the intensive care unit in 30 critically ill patients with confirmed COVID-19. RESULTS A different evolution of muscle thickness of the diaphragm and m. rectus femoris was observed; the changes between the two muscles were not correlated (Pearson's χ2 3.91, P = 0.419). The difference in muscle thickness was linked to the outcome for both m. rectus femoris and diaphragm, with the best survival seen in the group with stable muscle thickness. The greatest loss of muscle thickness occurred between days 5 and 10. The echo intensity was higher in the patients with increased muscle thickness, who also had a worse prognosis. There was a correlation between cross-sectional area on day 5 and handgrip strength (r = 0.290, P = 0.010). Only 31% of patients were able to return to their preadmission residence without any additional rehabilitation. CONCLUSIONS Muscle atrophy and decline in muscle strength appear in the earliest stages after admission to the intensive care unit and are related to functional outcome.
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Affiliation(s)
- Karolien Dams
- Intensive Care Department, Antwerp University Hospital, Edegem, Belgium; Laboratory of Experimental Medicine and Paediatrics (LEMP), Faculty of Medicine and Health Sciences, Antwerp, Belgium.
| | - Gregory Ra De Meyer
- Intensive Care Department, Antwerp University Hospital, Edegem, Belgium; Laboratory of Experimental Medicine and Paediatrics (LEMP), Faculty of Medicine and Health Sciences, Antwerp, Belgium; Department of Anaesthesiology, Antwerp University Hospital, Edegem, Belgium
| | - Rita Jacobs
- Intensive Care Department, Antwerp University Hospital, Edegem, Belgium
| | - Tom Schepens
- Intensive Care Department, Antwerp University Hospital, Edegem, Belgium; Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium; Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - Stany Perkisas
- University Centre of Geriatrics, University of Antwerp, Antwerp, Belgium
| | - Greta Moorkens
- Department of Internal Medicine, Antwerp University Hospital, Edegem, Belgium
| | - Philippe Jorens
- Intensive Care Department, Antwerp University Hospital, Edegem, Belgium; Laboratory of Experimental Medicine and Paediatrics (LEMP), Faculty of Medicine and Health Sciences, Antwerp, Belgium
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Panelli A, Grunow JJ, VERFUß MA, Bartels HG, Brass Z, Schaller SJ. Outcomes in critically ill patients after diaphragmatic stimulation on ventilator-induced diaphragmatic dysfunction: a systematic review. Eur J Phys Rehabil Med 2023; 59:772-781. [PMID: 38214045 PMCID: PMC10794987 DOI: 10.23736/s1973-9087.23.08031-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/11/2023] [Accepted: 10/09/2023] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Mechanical ventilation (MV) is a lifesaving procedure for critically ill patients. Diaphragm activation and stimulation may counteract side effects, such as ventilator-induced diaphragm dysfunction (VIDD). The effects of stimulation on diaphragm atrophy and patient outcomes are reported in this systematic review. EVIDENCE ACQUISITION Studies investigating diaphragmatic stimulation versus standard of care in critically ill patients and evaluating clinical outcomes were extracted from a Medline database last on January 23, 2023, after registration in Prospero (CRD42021259353). Selected studies included the investigation of diaphragmatic stimulation versus standard of care in critically ill patients, an evaluation of the clinical outcomes. These included muscle atrophy, VIDD, weaning failure, mortality, quality of life, ventilation time, diaphragmatic function, length of stay in the Intensive Care Unit (ICU), and length of hospital stay. All articles were independently evaluated by two reviewers according to their abstract and title and, secondly, a full texts evaluation by two independent reviewers was performed. To resolve diverging evaluations, a third reviewer was consulted to reach a final decision. Data were extracted by the reviewers following the Oxford 2011 levels of evidence guidelines and summarized accordingly. EVIDENCE SYNTHESIS Seven studies were extracted and descriptively synthesized, since a metanalysis was not feasible. Patients undergoing diaphragm stimulation had moderate evidence of higher maximal inspiratory pressure (MIP), less atrophy, less mitochondrial respiratory dysfunction, less oxidative stress, less molecular atrophy, shorter MV time, shorter ICU length of stay, longer survival, and better SF-36 scores than control. CONCLUSIONS Evidence of the molecular and histological benefits of diaphragmatic stimulation is limited. The results indicate positive clinical effects of diaphragm activation with a moderate level of evidence for MIP and a low level of evidence for other outcomes. Diaphragm activation could be a therapeutic solution to avoid diaphragm atrophy, accelerate weaning, shorten MV time, and counteract VIDD; however, better-powered studies are needed to increase the level of evidence.
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Affiliation(s)
- Alessandro Panelli
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin, Berlin, Germany
| | - Julius J Grunow
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin, Berlin, Germany
| | - Michael A VERFUß
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin, Berlin, Germany
| | - Hermann G Bartels
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin, Berlin, Germany
| | - Zarina Brass
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Stefan J Schaller
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin, Berlin, Germany -
- School of Medicine, Department of Anesthesiology and Intensive Care, Klinikum rechts der Isar Hospital, School of Medicine and Health, Technical University of Munich, Munich, Germany
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18
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Lin C, Chao WC, Pai KC, Yang TY, Wu CL, Chan MC. Prolonged use of neuromuscular blocking agents is associated with increased long-term mortality in mechanically ventilated medical ICU patients: a retrospective cohort study. J Intensive Care 2023; 11:55. [PMID: 37978572 PMCID: PMC10655355 DOI: 10.1186/s40560-023-00696-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/23/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Neuromuscular blockade agents (NMBAs) can be used to facilitate mechanical ventilation in critically ill patients. Accumulating evidence has shown that NMBAs may be associated with intensive care unit (ICU)-acquired weakness and poor outcomes. However, the long-term impact of NMBAs on mortality is still unclear. METHODS We conducted a retrospective analysis using the 2015-2019 critical care databases at Taichung Veterans General Hospital, a referral center in central Taiwan, as well as the Taiwan nationwide death registry profile. RESULTS A total of 5709 ventilated patients were eligible for further analysis, with 63.8% of them were male. The mean age of enrolled subjects was 67.8 ± 15.8 years, and the one-year mortality was 48.3% (2755/5709). Compared with the survivors, the non-survivors had a higher age (70.4 ± 14.9 vs 65.4 ± 16.3, p < 0.001), Acute Physiology and Chronic Health Evaluation II score (28.0 ± 6.2 vs 24.7 ± 6.5, p < 0.001), a longer duration of ventilator use (12.6 ± 10.6 days vs 7.8 ± 8.5 days, p < 0.001), and were more likely to receive NMBAs for longer than 48 h (11.1% vs 7.8%, p < 0.001). After adjusting for age, sex, and relevant covariates, the use of NMBAs for longer than 48 h was found to be independently associated with an increased risk of mortality (adjusted HR: 1.261; 95% CI: 1.07-1.486). The analysis of effect modification revealed that this association was tended to be strong in patients with a Charlson Comorbidity Index of 3 or higher. CONCLUSIONS Our study demonstrated that prolonged use of NMBAs was associated with an increased risk of long-term mortality in critically ill patients requiring mechanical ventilation. Further studies are needed to validate our findings.
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Affiliation(s)
- Chun Lin
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wen-Cheng Chao
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Automatic Control Engineering, Feng Chia University, Taichung, Taiwan
- Big Data Center, Chung Hsing University, Taichung, Taiwan
| | - Kai-Chih Pai
- College of Engineering, Tunghai University, Taichung, Taiwan
| | - Tsung-Ying Yang
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Life Sciences, National Chung Hsing University, Taichung, Taiwan
| | - Chieh-Liang Wu
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Ming-Cheng Chan
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan.
- Division of Critical Care and Respiratory Therapy, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.
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Takahashi Y, Morisawa T, Okamoto H, Nakanishi N, Matsumoto N, Saitoh M, Takahashi T, Fujiwara T. Diaphragm Dysfunction and ICU-Acquired Weakness in Septic Shock Patients with or without Mechanical Ventilation: A Pilot Prospective Observational Study. J Clin Med 2023; 12:5191. [PMID: 37629233 PMCID: PMC10455261 DOI: 10.3390/jcm12165191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/05/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Sepsis is a risk factor for diaphragm dysfunction and ICU-acquired weakness (ICU-AW); however, the impact of mechanical ventilation (MV) on these relationships has not been thoroughly investigated. This study aimed to compare the incidence of diaphragm dysfunction and ICU-AW in patients with septic shock, with and without MV. We conducted a single-center prospective observational study that included consecutive patients diagnosed with septic shock admitted to the ICU between March 2021 and February 2022. Ultrasound measurements of diaphragm thickness and manual measurements of limb muscle strength were repeated after ICU admission. The incidences of diaphragm dysfunction and ICU-AW, as well as their associations with clinical outcomes, were compared between patients with MV and without MV (non-MV). Twenty-four patients (11 in the MV group and 13 in the non-MV group) were analyzed. At the final measurements in the MV group, eight patients (72.7%) had diaphragm dysfunction, and six patients (54.5%) had ICU-AW. In the non-MV group, 10 patients (76.9%) had diaphragm dysfunction, and three (23.1%) had ICU-AW. No association was found between diaphragm dysfunction and clinical outcomes. Patients with ICU-AW in the MV group had longer ICU and hospital stays. Among patients with septic shock, the incidence of diaphragm dysfunction was higher than that of ICU-AW, irrespective of the use of MV. Further studies are warranted to examine the association between diaphragm dysfunction and clinical outcomes.
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Affiliation(s)
- Yuta Takahashi
- Department of Rehabilitation Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (Y.T.); (T.F.)
- Department of Rehabilitation, St. Luke’s International Hospital, Tokyo 104-8560, Japan
| | - Tomoyuki Morisawa
- Department of Physical Therapy, Faculty of Health Science, Juntendo University, Tokyo 113-8421, Japan; (M.S.); (T.T.)
| | - Hiroshi Okamoto
- Department of Critical Care Medicine, St. Luke’s International Hospital, Tokyo 104-8560, Japan;
| | - Nobuto Nakanishi
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan;
| | - Noriko Matsumoto
- Department of Nutrition, St. Luke’s International Hospital, Tokyo 104-8560, Japan;
| | - Masakazu Saitoh
- Department of Physical Therapy, Faculty of Health Science, Juntendo University, Tokyo 113-8421, Japan; (M.S.); (T.T.)
| | - Tetsuya Takahashi
- Department of Physical Therapy, Faculty of Health Science, Juntendo University, Tokyo 113-8421, Japan; (M.S.); (T.T.)
| | - Toshiyuki Fujiwara
- Department of Rehabilitation Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (Y.T.); (T.F.)
- Department of Physical Therapy, Faculty of Health Science, Juntendo University, Tokyo 113-8421, Japan; (M.S.); (T.T.)
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20
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Wakefield CJ, Jochum SB, Hejna EE, Peterson SB, Vines DL, Shah PN, Hayden DM, Balk RA. Respiratory Musculature Evaluated by Computed Tomography in the Setting of Prolonged Mechanical Ventilation. Respir Care 2023; 68:1106-1111. [PMID: 37185112 PMCID: PMC10353160 DOI: 10.4187/respcare.09491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND Diaphragm atrophy has been observed in subjects who undergo invasive mechanical ventilation. We propose a new method to assess for respiratory muscle (RM) changes in subjects who undergo invasive mechanical ventilation by assessing for changes in respiratory muscles through computed tomography (CT). METHODS A retrospective case series study was conducted on subjects who underwent invasive mechanical ventilation and received at least 2 chest CT scans during admission. Exclusion criteria included history of chronic mechanical ventilation dependence and neuromuscular disease. Respiratory muscle cross-sectional area (CSA) was measured at the T6 vertebrae. RESULTS Fourteen subjects were included: mean (± SD) age, BMI, and admission APACHE II scores were 54.0 y (± 14.9), 32.6 kg/m2 (± 10.9), and 23.5 (± 6.0), respectively. Ten (71%) subjects were male. Mean length of time between CT chest scans was 7.5 d (± 3.3). Mean duration of invasive mechanical ventilation was 4.5 d (± 3.4). The percentage change in TM CSA among those who underwent invasive mechanical ventilation was 10.5% (± 6.1). CONCLUSIONS We demonstrated that serial analysis of respiratory muscle CSA through CT chest scans can be a method to assess for respiratory muscle atrophy in subjects undergoing mechanical ventilation. Future prospective studies involving larger populations are needed to better understand how this method can be used to predict outcomes in mechanically ventilated patients.
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Affiliation(s)
- Connor J Wakefield
- Department of Internal Medicine, Brooke Army Medical Center, San Antonio, Texas.
| | - Sarah B Jochum
- Department of Surgery, Division of Colon and Rectal Surgery, Rush University Medical Center, Chicago, Illinois
| | - Emily E Hejna
- Department of Surgery, Division of Colon and Rectal Surgery, Rush University Medical Center, Chicago, Illinois
| | - Sarah B Peterson
- Department of Clinical Nutrition, College of Health Sciences, Rush University Medical Center, Chicago, Illinois
| | - David L Vines
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois
| | - Palmi N Shah
- Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, Chicago, Illinois
| | - Dana M Hayden
- Department of Surgery, Division of Colon and Rectal Surgery, Rush University Medical Center, Chicago, Illinois
| | - Robert A Balk
- Department of Internal Medicine, Brooke Army Medical Center, San Antonio, Texas
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21
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Bureau C, Van Hollebeke M, Dres M. Managing respiratory muscle weakness during weaning from invasive ventilation. Eur Respir Rev 2023; 32:220205. [PMID: 37019456 PMCID: PMC10074167 DOI: 10.1183/16000617.0205-2022] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/08/2022] [Indexed: 04/07/2023] Open
Abstract
Weaning is a critical stage of an intensive care unit (ICU) stay, in which the respiratory muscles play a major role. Weakness of the respiratory muscles, which is associated with significant morbidity in the ICU, is not limited to atrophy and subsequent dysfunction of the diaphragm; the extradiaphragmatic inspiratory and expiratory muscles also play important parts. In addition to the well-established deleterious effect of mechanical ventilation on the respiratory muscles, other risk factors such as sepsis may be involved. Weakness of the respiratory muscles can be suspected visually in a patient with paradoxical movement of the abdominal compartment. Measurement of maximal inspiratory pressure is the simplest way to assess respiratory muscle function, but it does not specifically take the diaphragm into account. A cut-off value of -30 cmH2O could identify patients at risk for prolonged ventilatory weaning; however, ultrasound may be better for assessing respiratory muscle function in the ICU. Although diaphragm dysfunction has been associated with weaning failure, this diagnosis should not discourage clinicians from performing spontaneous breathing trials and considering extubation. Recent therapeutic developments aimed at preserving or restoring respiratory muscle function are promising.
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Affiliation(s)
- Côme Bureau
- Sorbonne Université, INSERM, UMR_S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation, Département R3S, Paris, France
| | - Marine Van Hollebeke
- KU Leuven - University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Martin Dres
- Sorbonne Université, INSERM, UMR_S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation, Département R3S, Paris, France
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22
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Temporal evolution of diaphragm thickness and diaphragm excursion among subjects hospitalized with COVID-19: A prospective observational study. Respir Med Res 2023; 83:100960. [PMID: 36563547 PMCID: PMC9770987 DOI: 10.1016/j.resmer.2022.100960] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/09/2022] [Accepted: 09/26/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has an affinity for the angiotensin-converting enzyme 2 (ACE2) receptors, which are present abundantly on the diaphragm. This study aims to describe temporal changes in diaphragmatic thickness and excursion using ultrasonography in subjects with acute COVID-19. METHODS This prospective observational study included adults hospitalized with COVID-19 in the past 48 hours. The diaphragm thickness at end-expiration (DTE), diaphragm thickening fraction (DTF), and diaphragm excursion during tidal breathing (DE) and maximal inspiration (DEmax) were measured using ultrasonography daily for 5 days. The changes in DTE, DTF, DE, and Demax from day 1 to day 5 were assessed. RESULTS This study included 64 adults (62.5% male) with a mean (SD) age of 50.2 (17.5) years. A majority (91%) of the participants had mild or moderate illness. The median (IQR) DTE, DTF (%), DE and Demax on day 1 were 2.2 (1.9, 3.0) mm, 21.5% (14.2, 31.0), 19.2 (16.5, 24.0) mm, and 26.7 (22.0, 30.2) mm, respectively. On day 5, there was a significant reduction in the DTE (p=0.002) with a median (IQR) percentage change of -15.7% (-21.0, 0.0). The DTF significantly increased on day 5 with a median (IQR) percentage change of 25.0% (-19.2, 98.4), p=0.03. There was no significant change in DE and Demax from day 1 to day 5, with a median (IQR) percentage change of 3.6% (-5.2, 15) and 0% (-6.7, 5.9), respectively. CONCLUSIONS Non-intubated patients with COVID-19 exhibited a temporal decline in diaphragm thickness with increase in thickening fraction over 5 days of hospital admission. Further research is warranted to assess the impact of COVID-19 pneumonia on diaphragmatic function.
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23
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Morgan L, Hollist M, Au K, Ayari L, Betts C, Kirmani BF. Neuromuscular Disorders Associated With COVID-19. Neurosci Insights 2023; 18:26331055231176251. [PMID: 37255741 PMCID: PMC10225906 DOI: 10.1177/26331055231176251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/01/2023] [Indexed: 06/01/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has had an enormous impact on practically every aspect of daily life, and those with neuromuscular disorders have certainly not been spared. The effects of COVID-19 infection are far-reaching, going well beyond respiratory symptoms alone. From simple myalgias to debilitating critical illness neuromyopathies, we continue to learn and catalog the diverse pathologies presented by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as it relates to the neuromuscular system. Complications have been documented both as a direct result of primary infection but also in those with pre-existing neuromuscular disorders from myasthenia gravis to devastating critical illness neuromyopathies. In this review, we will discuss the relationship between COVID-19 infection and critical illness neuromyopathy, peripheral nerve palsies, myalgias, positional compressive neuropathy, myasthenia gravis, and Guillain-Barré syndrome.
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Affiliation(s)
| | | | | | - Lena Ayari
- Texas A&M University School of
Medicine, Bryan, TX, USA
| | - Colton Betts
- Texas A&M University School of
Medicine, Bryan, TX, USA
| | - Batool F Kirmani
- Texas A&M University School of
Medicine, Bryan, TX, USA
- Department of Neurology, CHI St. Joseph
Health, Bryan, TX, USA
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24
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Mueller G, Aszalos E, Krause S, Niederhauser T, Slavei K, Baumberger ME. Safety and Feasibility of Noninvasive Electromagnetic Stimulation of the Phrenic Nerves. Respir Care 2023; 68:602-610. [PMID: 36878642 PMCID: PMC10171341 DOI: 10.4187/respcare.10568] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
BACKGROUND Mechanical ventilation is widely used in ICU patients as a lifesaving intervention. Diaphragmatic atrophy and thinning occur from lack of contractions of the diaphragm during mechanical ventilation. It may prolong weaning and increase the risk of respiratory complications. Noninvasive electromagnetic stimulation of the phrenic nerves may ameliorate the atrophy seen with ventilation. The objective of this study was to show that noninvasive repetitive electromagnetic stimulation is safe, feasible, and effective to stimulate the phrenic nerves in both awake individuals and anesthetized patients. METHODS A single-center study with 10 subjects overall, 5 awake volunteers and 5 anesthetized subjects. We used a prototype electromagnetic, noninvasive, simultaneous bilateral phrenic nerve stimulation device in both groups. In the awake volunteers, we assessed time-to-first capture of the phrenic nerves and safety measures, such as pain, discomfort, dental paresthesia, and skin irritation. In the anesthetized subjects, time-to-first capture as well as tidal volumes and airway pressures at 20%, 30%, and 40% stimulation intensity were assessed. RESULTS Diaphragmatic capture was achieved in all the subjects within a median (range) of 1 min (1 min to 9 min 21 s) for the awake subjects and 30 s (20 s to 1 min 15 s) for the anesthetized subjects. There were no adverse or severe adverse events in either group, nor any dental paresthesia, skin irritation, or subjective pain in the stimulated area. Tidal volumes increased in all the subjects in response to simultaneous bilateral phrenic nerve stimulation and increased gradually with increasing stimulation intensity. Airway pressures corresponded to spontaneous breathing of ∼2 cm H2O. CONCLUSIONS Noninvasive phrenic nerve stimulation can be safely performed in awake and anesthetized individuals. It was feasible and effective in stimulating the diaphragm by induction of physiologic and scalable tidal volumes with minimum positive airway pressures.
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Affiliation(s)
- Gabi Mueller
- Clinical Trial Unit, Swiss Paraplegic Center, Nottwil, Switzerland.
| | - Elöd Aszalos
- Anesthesiology, Swiss Paraplegic Center, Nottwil, Switzerland
| | - Sven Krause
- Institute for Human Centered Engineering, Bern University of Applied Sciences, Biel, Switzerland
| | - Thomas Niederhauser
- Institute for Human Centered Engineering, Bern University of Applied Sciences, Biel, Switzerland
| | | | - Michael E Baumberger
- Paraplegiology and Rehabilitation, Swiss Paraplegic Center, Nottwil, Switzerland
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25
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Duyndam A, Smit J, Heunks L, Molinger J, IJland M, van Rosmalen J, van Dijk M, Tibboel D, Ista E. Reference values of diaphragmatic dimensions in healthy children aged 0-8 years. Eur J Pediatr 2023:10.1007/s00431-023-04920-6. [PMID: 36939879 DOI: 10.1007/s00431-023-04920-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 03/21/2023]
Abstract
Diaphragmatic thickness (Tdi) and diaphragm thickening fraction (dTF) are widely used parameters in ultrasound studies of the diaphragm in mechanically ventilated children, but normal values for healthy children are scarce. We determined reference values of Tdi and dTF using ultrasound in healthy children aged 0-8 years old and assessed their reproducibility. In a prospective, observational cohort, Tdi and dTF were measured on ultrasound images across four age groups comprising at least 30 children per group: group 1 (0-6 months), group 2 (7 months-1 year), group 3 (2-4 years) and group 4 (5-8 years). Ultrasound images of 137 healthy children were included. Mean Tdi at inspiration was 2.07 (SD 0.40), 2.09 (SD 0.40), 1.69 (SD 0.30) and 1.72 (SD 0.30) mm for groups 1, 2, 3 and 4, respectively. Mean Tdi at expiration was 1.64 (SD 0.30), 1.67 (SD 0.30), 1.38 (SD 0.20) and 1.42 (SD 0.20) mm for groups 1, 2, 3 and 4, respectively. Mean Tdi at inspiration and mean Tdi at expiration for groups 1 and 2 were significantly greater than those for groups 3 and 4 (both p < 0.001). Mean dTF was 25.4% (SD 10.4), 25.2% (SD 8.3), 22.8% (SD 10.9) and 21.3% (SD 7.1) for group 1, 2, 3 and 4, respectively. The intraclass correlation coefficients (ICC) representing the level of inter-rater reliability between two examiners performing the ultrasounds was 0.996 (95% CI 0.982-0.999). ICC of the inter-rater reliability between the raters in 11 paired assessments was 0.989 (95% CI 0.973-0.995). Conclusion: Ultrasound measurements of Tdi and dTF were highly reproducible in healthy children aged 0-8 years. Trial registration: ClinicalTrials.gov identifier (NCT number): NCT04589910. What is Known: • Diaphragmatic thickness and diaphragm thickening fraction are widely used parameters in ultrasound studies of the diaphragm in mechanically ventilated children, but normal values for healthy children to compare these with are scarce. What is New: • We determined normal values of diaphragmatic thickness and diaphragm thickening fraction using ultrasound in 137 healthy children aged 0-8 years old. The diaphragmatic thickness of infants up to 1 year old was significantly greater than that of children from 2 to 8 years old. Diaphragmatic thickness decreased with an increase in body surface area. These normal values in healthy children can be used to assess changes in respiratory muscle thickness in mechanically ventilated children.
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Affiliation(s)
- Anita Duyndam
- Department of Pediatric Surgery and Intensive Care, Erasmus , Sophia Children's Hospital, MC, Rotterdam, the Netherlands.
| | - Joke Smit
- Department of Pediatric Surgery and Intensive Care, Erasmus , Sophia Children's Hospital, MC, Rotterdam, the Netherlands
| | - Leo Heunks
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jeroen Molinger
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Division of Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Marloes IJland
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Monique van Dijk
- Department of Pediatric Surgery and Intensive Care, Erasmus , Sophia Children's Hospital, MC, Rotterdam, the Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery and Intensive Care, Erasmus , Sophia Children's Hospital, MC, Rotterdam, the Netherlands.,Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Erwin Ista
- Department of Pediatric Surgery and Intensive Care, Erasmus , Sophia Children's Hospital, MC, Rotterdam, the Netherlands
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26
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Santana PV, Cardenas LZ, de Albuquerque ALP. Diaphragm Ultrasound in Critically Ill Patients on Mechanical Ventilation—Evolving Concepts. Diagnostics (Basel) 2023; 13:diagnostics13061116. [PMID: 36980423 PMCID: PMC10046995 DOI: 10.3390/diagnostics13061116] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving respiratory support therapy, but MV can lead to diaphragm muscle injury (myotrauma) and induce diaphragmatic dysfunction (DD). DD is relevant because it is highly prevalent and associated with significant adverse outcomes, including prolonged ventilation, weaning failures, and mortality. The main mechanisms involved in the occurrence of myotrauma are associated with inadequate MV support in adapting to the patient’s respiratory effort (over- and under-assistance) and as a result of patient-ventilator asynchrony (PVA). The recognition of these mechanisms associated with myotrauma forced the development of myotrauma prevention strategies (MV with diaphragm protection), mainly based on titration of appropriate levels of inspiratory effort (to avoid over- and under-assistance) and to avoid PVA. Protecting the diaphragm during MV therefore requires the use of tools to monitor diaphragmatic effort and detect PVA. Diaphragm ultrasound is a non-invasive technique that can be used to monitor diaphragm function, to assess PVA, and potentially help to define diaphragmatic effort with protective ventilation. This review aims to provide clinicians with an overview of the relevance of DD and the main mechanisms underlying myotrauma, as well as the most current strategies aimed at minimizing the occurrence of myotrauma with special emphasis on the role of ultrasound in monitoring diaphragm function.
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Affiliation(s)
- Pauliane Vieira Santana
- Intensive Care Unit, AC Camargo Cancer Center, São Paulo 01509-011, Brazil
- Correspondence: (P.V.S.); (A.L.P.d.A.)
| | - Letícia Zumpano Cardenas
- Intensive Care Unit, Physical Therapy Department, AC Camargo Cancer Center, São Paulo 01509-011, Brazil
| | - Andre Luis Pereira de Albuquerque
- Pulmonary Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
- Sírio-Libanês Teaching and Research Institute, Hospital Sírio Libanês, São Paulo 01308-060, Brazil
- Correspondence: (P.V.S.); (A.L.P.d.A.)
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27
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Diaphragm function in patients with sepsis and septic shock: A longitudinal ultrasound study. Aust Crit Care 2023; 36:239-246. [PMID: 35272911 DOI: 10.1016/j.aucc.2022.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/23/2021] [Accepted: 01/13/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Previous literature on the determinants of diaphragm dysfunction in septic patients is limited. The goal of this study is to assess diaphragm dysfunction in terms of its prevalence and its potential associated factors in septic intensive care unit (ICU) patients. METHODS This prospective and observational study was conducted between June 2015 and July 2019. Ultrasound measures of diaphragm thickness were performed daily on septic patients. The primary outcome was the prevalence of diaphragm dysfunction at baseline and during the ICU stay. The secondary outcome was the diaphragm thickness. Possible associated factors were prospectively recorded. RESULTS Fifty patients were enrolled in the study. The prevalence of diaphragm dysfunction was 58%. No diaphragm atrophy was found during the ICU stay. Diaphragm dysfunction was associated with the alteration of consciousness, intra-abdominal sepsis, hypnotics and opioids, and mechanical ventilation. Administration of hypnotics, opioids, and steroids was associated with a decreased diaphragm thickening fraction. Diaphragm dysfunction had no impact on patient outcomes. CONCLUSIONS Our data reveal a high prevalence of diaphragm dysfunction in septic patients at the onset of sepsis. Administration of hypnotics, opioids, and steroids was associated with the alteration of diaphragm function as well as intra-abdominal sepsis.
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28
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Safai Zadeh E, Görg C, Prosch H, Horn R, Jenssen C, Dietrich CF. The Role of Thoracic Ultrasound for Diagnosis of Diseases of the Chest Wall, the Mediastinum, and the Diaphragm-Narrative Review and Pictorial Essay. Diagnostics (Basel) 2023; 13:767. [PMID: 36832255 PMCID: PMC9956010 DOI: 10.3390/diagnostics13040767] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/29/2023] [Accepted: 02/08/2023] [Indexed: 02/22/2023] Open
Abstract
The diagnostic capabilities of ultrasound extend far beyond the evaluation of the pleural space and lungs. Sonographic evaluation of the chest wall is a classic extension of the clinical examination of visible, palpable, or dolent findings. Unclear mass lesions of the chest wall can be differentiated accurately and with low risk by additional techniques such as color Doppler imaging, contrast-enhanced ultrasound, and, in particular, ultrasound-guided biopsy. For imaging of mediastinal pathologies, ultrasound has only a complementary function but is valuable for guidance of percutaneous biopsies of malignant masses. In emergency medicine, ultrasound can verify and support correct positioning of endotracheal tubes. Diaphragmatic ultrasound benefits from the real-time nature of sonographic imaging and is becoming increasingly important for the assessment of diaphragmatic function in long-term ventilated patients. The clinical role of thoracic ultrasound is reviewed in a combination of narrative review and pictorial essay.
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Affiliation(s)
- Ehsan Safai Zadeh
- Gastroenterology, Endocrinology, Metabolism and Clinical Infectiology, Interdisciplinary Center of Ultrasound Diagnostics, University Hospital Giessen and Marburg, Philipps University Marburg, Baldingerstraße, 35033 Marburg, Germany
| | - Christian Görg
- Gastroenterology, Endocrinology, Metabolism and Clinical Infectiology, Interdisciplinary Center of Ultrasound Diagnostics, University Hospital Giessen and Marburg, Philipps University Marburg, Baldingerstraße, 35033 Marburg, Germany
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna General Hospital, 1090 Vienna, Austria
| | - Rudolf Horn
- Center da Sandà Val Müstair, 7536 Sta. Maria, Switzerland
| | - Christian Jenssen
- Medical Department, Krankenhaus Maerkisch-Oderland, 15344 Strausberg, Germany
- Brandenburg Institute of Clinical Ultrasound, Medical University Brandenburg, 16816 Neuruppin, Germany
| | - Christoph Frank Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Bern, Beau Site, Salem und Permanence, 3018 Bern, Switzerland
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29
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Ribeiro F, Alves PKN, Bechara LRG, Ferreira JCB, Labeit S, Moriscot AS. Small-Molecule Inhibition of MuRF1 Prevents Early Disuse-Induced Diaphragmatic Dysfunction and Atrophy. Int J Mol Sci 2023; 24:ijms24043637. [PMID: 36835047 PMCID: PMC9965746 DOI: 10.3390/ijms24043637] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
In clinical conditions such as diaphragm paralysis or mechanical ventilation, disuse-induced diaphragmatic dysfunction (DIDD) is a condition that poses a threat to life. MuRF1 is a key E3-ligase involved in regulating skeletal muscle mass, function, and metabolism, which contributes to the onset of DIDD. We investigated if the small-molecule mediated inhibition of MuRF1 activity (MyoMed-205) protects against early DIDD after 12 h of unilateral diaphragm denervation. Wistar rats were used in this study to determine the compound's acute toxicity and optimal dosage. For potential DIDD treatment efficacy, diaphragm contractile function and fiber cross-sectional area (CSA) were evaluated. Western blotting investigated potential mechanisms underlying MyoMed-205's effects in early DIDD. Our results indicate 50 mg/kg bw MyoMed-205 as a suitable dosage to prevent early diaphragmatic contractile dysfunction and atrophy following 12 h of denervation without detectable signs of acute toxicity. Mechanistically, treatment did not affect disuse-induced oxidative stress (4-HNE) increase, whereas phosphorylation of (ser632) HDAC4 was normalized. MyoMed-205 also mitigated FoxO1 activation, inhibited MuRF2, and increased phospho (ser473) Akt protein levels. These findings may suggest that MuRF1 activity significantly contributes to early DIDD pathophysiology. Novel strategies targeting MuRF1 (e.g., MyoMed-205) have potential therapeutic applications for treating early DIDD.
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Affiliation(s)
- Fernando Ribeiro
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil
| | - Paula K. N. Alves
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil
| | - Luiz R. G. Bechara
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil
| | - Julio C. B. Ferreira
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil
| | - Siegfried Labeit
- DZHK Partner Site Mannheim-Heidelberg, Medical Faculty Mannheim, University of Heidelberg, 68169 Mannheim, Germany
- Myomedix GmbH, 69151 Neckargemünd, Germany
| | - Anselmo S. Moriscot
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil
- Correspondence: ; Tel.: +55-11-3091-0946
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30
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Gan XY, Zhang J, Xu P, Liu SJ, Guo ZL. Early passive orthostatic training prevents diaphragm atrophy and dysfunction in intensive care unit patients on mechanical ventilation: A retrospective case‒control study. Heart Lung 2023; 59:37-43. [PMID: 36709529 DOI: 10.1016/j.hrtlng.2023.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 01/29/2023]
Abstract
BACKGROUND Intensive care unit (ICU) patients on mechanical ventilation (MV), who are always bedridden, easily develop diaphragm atrophy and dysfunction. However, few studies have assessed diaphragmatic thickness and functional changes after early passive orthostatic training. OBJECTIVES This is the first study to investigate the efficacy of early passive orthostatic training in preventing diaphragm atrophy and dysfunction in ICU patients on MV. METHODS In this randomized retrospective case‒control study, 81 ICU patients on MV for 8 days or longer were enrolled. Forty-four patients received early passive orthostatic training initiated within 72 h of MV initiation (training group), and 37 patients did not receive training (no-training group). The protocol was performed for seven days, once a day for 30 min. The primary outcomes were diaphragmatic thickness and diaphragm contractile fraction (TFdi). The ventilatory parameters were secondary outcomes. RESULTS This study included 81 (45 male) ICU patients on MV [(mean ± SD) age = (60.63 ± 7.88) years]. The training group had a larger diaphragmatic thickness at end-expiration (Tdi,ee) and a smaller magnitude of decrease in Tdi,ee and TFdi (p = 0.001, 0.029, and <0.001, respectively) than the no-training group after 7 days of training. The mean arterial pressure, fraction of inspired oxygen, and white blood cell levels were decreased in the training group compared with the no-training group (p = 0.003, 0.001, and 0.026, respectively), but lactic acid levels decreased slightly in the training group with no significant difference (p = 0.708). CONCLUSIONS Early passive orthostatic training is suitable to ameliorate diaphragm atrophy and dysfunction in ICU patients on MV.
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Affiliation(s)
- Xin-Yu Gan
- Department of Rehabilitation, Beidahuang Industry Group General Hospital, 235 Hashuang Road, Nangang District, Harbin, Heilongjiang 150000, China
| | - Jun Zhang
- Department of Rehabilitation, Beidahuang Industry Group General Hospital, 235 Hashuang Road, Nangang District, Harbin, Heilongjiang 150000, China.
| | - Ping Xu
- Department of Rehabilitation, Beidahuang Industry Group General Hospital, 235 Hashuang Road, Nangang District, Harbin, Heilongjiang 150000, China
| | - Si-Jin Liu
- Department of Nursing, Harbin Medical University, Daqing, Heilongjiang 163319, China
| | - Zhi-Lin Guo
- Department of Rehabilitation, Beidahuang Industry Group General Hospital, 235 Hashuang Road, Nangang District, Harbin, Heilongjiang 150000, China
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31
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Giberson CE, Cheshier SH, Poree LR, Saulino MF. Diaphragm Pacing: A Safety, Appropriateness, Financial Neutrality, and Efficacy Analysis of Treating Chronic Respiratory Insufficiency. Neuromodulation 2023; 26:490-497. [PMID: 36609087 DOI: 10.1016/j.neurom.2022.10.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 10/19/2022] [Accepted: 10/31/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVES This study aimed to evaluate the safety and applicability of treating chronic respiratory insufficiency with diaphragm pacing relative to mechanical ventilation. MATERIALS AND METHODS A literature review and analysis were conducted using the safety, appropriateness, financial neutrality, and efficacy principles. RESULTS Although mechanical ventilation is clearly indicated in acute respiratory failure, diaphragm pacing improves life expectancy, increases quality of life, and reduces complications in patients with chronic respiratory insufficiency. CONCLUSION Diaphragm pacing should be given more consideration in appropriately selected patients with chronic respiratory insufficiency.
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32
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Wittenstein J, Huhle R, Leiderman M, Möbius M, Braune A, Tauer S, Herzog P, Barana G, de Ferrari A, Corona A, Bluth T, Kiss T, Güldner A, Schultz MJ, Rocco PRM, Pelosi P, Gama de Abreu M, Scharffenberg M. Effect of patient-ventilator asynchrony on lung and diaphragmatic injury in experimental acute respiratory distress syndrome in a porcine model. Br J Anaesth 2023; 130:e169-e178. [PMID: 34895719 DOI: 10.1016/j.bja.2021.10.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 10/07/2021] [Accepted: 10/08/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Patient-ventilator asynchrony during mechanical ventilation may exacerbate lung and diaphragm injury in spontaneously breathing subjects. We investigated whether subject-ventilator asynchrony increases lung or diaphragmatic injury in a porcine model of acute respiratory distress syndrome (ARDS). METHODS ARDS was induced in adult female pigs by lung lavage and injurious ventilation before mechanical ventilation by pressure assist-control for 12 h. Mechanically ventilated pigs were randomised to breathe spontaneously with or without induced subject-ventilator asynchrony or neuromuscular block (n=7 per group). Subject-ventilator asynchrony was produced by ineffective, auto-, or double-triggering of spontaneous breaths. The primary outcome was mean alveolar septal thickness (where thickening of the alveolar wall indicates worse lung injury). Secondary outcomes included distribution of ventilation (electrical impedance tomography), lung morphometric analysis, inflammatory biomarkers (gene expression), lung wet-to-dry weight ratio, and diaphragmatic muscle fibre thickness. RESULTS Subject-ventilator asynchrony (median [interquartile range] 28.8% [10.4] asynchronous breaths of total breaths; n=7) did not increase mean alveolar septal thickness compared with synchronous spontaneous breathing (asynchronous breaths 1.0% [1.6] of total breaths; n=7). There was no difference in mean alveolar septal thickness throughout upper and lower lung lobes between pigs randomised to subject-ventilator asynchrony vs synchronous spontaneous breathing (87.3-92.2 μm after subject-ventilator asynchrony, compared with 84.1-95.0 μm in synchronised spontaneous breathing;). There were also no differences between groups in wet-to-dry weight ratio, diaphragmatic muscle fibre thickness, atelectasis, lung aeration, or mRNA expression levels for inflammatory cytokines pivotal in ARDS pathogenesis. CONCLUSIONS Subject-ventilator asynchrony during spontaneous breathing did not exacerbate lung injury and dysfunction in experimental porcine ARDS.
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Affiliation(s)
- Jakob Wittenstein
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Robert Huhle
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Mark Leiderman
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Marius Möbius
- Neonatology and Pediatric Critical Care Medicine, Department of Pediatrics, University Hospital and Medical Faculty Carl Gustav Carus, Dresden, Germany
| | - Anja Braune
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Nuclear Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Sebastian Tauer
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Paul Herzog
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Giulio Barana
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Anaesthesiology, Hospital Thurgau AG, Frauenfeld, Switzerland
| | - Alessandra de Ferrari
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Anaesthesia and Intensive Care, IRCCS AOU San Martino IST, Genoa, Italy
| | - Andrea Corona
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Anaesthesiology and Intensive Care, Mater Olbia Hospital, Olbia, Italy
| | - Thomas Bluth
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Thomas Kiss
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Anaesthesiology, Intensive-, Pain- and Palliative Care Medicine, Radebeul Hospital, Academic Hospital of the Technische Universität Dresden, Radebeul, Germany
| | - Andreas Güldner
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Marcus J Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Martin Scharffenberg
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
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Spinelli E, Slobod D, Mauri T. Personalised PEEP that yields the highest lung compliance versus optimal balance between overdistension and collapse during PSV: authors' reply to Dr Stenqvist. Crit Care 2022; 26:381. [PMID: 36494751 PMCID: PMC9733088 DOI: 10.1186/s13054-022-04261-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022] Open
Affiliation(s)
- Elena Spinelli
- grid.414818.00000 0004 1757 8749Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milan, Italy
| | - Douglas Slobod
- grid.14709.3b0000 0004 1936 8649Department of Critical Care Medicine, McGill University, Montreal, QC Canada
| | - Tommaso Mauri
- grid.414818.00000 0004 1757 8749Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milan, Italy ,grid.4708.b0000 0004 1757 2822Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Shah AJ, Wai K, Sharron MP, Mize M, Cohen J, Basu S. Diaphragmatic Thickening Fraction by Ultrasound in Mechanically Ventilated Pediatric Patients: Pilot Observations During Spontaneous Breathing Trials. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:3043-3050. [PMID: 35670278 DOI: 10.1002/jum.16035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 04/21/2022] [Accepted: 05/06/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES In critically ill, mechanically ventilated adults, diaphragmatic atrophy and reduced diaphragmatic thickening fraction (DTF) has been associated with poor extubation outcomes. Diaphragmatic ultrasound assessment in critically ill pediatric patients shows similar results, though studies are on-going. We sought to explore the feasibility and utility of using DTF, obtained during a spontaneous breathing trial (SBT) in predicting weaning outcomes. METHODS We conducted a prospective, observational study in a single-center tertiary noncardiac pediatric intensive care unit (PICU) in a children's hospital. Mechanically ventilated pediatric patients were included except for those with preexisting conditions of neuromuscular weakness, diaphragm paresis, or chronic respiratory failure requiring non-invasive or invasive mechanical ventilation at baseline. A convenience sample of 38 patients were included in the study. RESULTS Weaning failure occurred in 10/38 (26%) instances with 9/38 (24%) occurring due to failed SBT and 1/38 (2%) due to failed extubation requiring reintubation. Median DTF was 24% (IQR: 12-33). DTF was significantly lower in instances of failed SBT, 12% compared to 27% (P < .01). The odds ratio (OR) of SBT failure utilizing: TF < 25% is 12 (CI: 1.33-108.0, Z-score: 2.22, P = .027), TV <5 mL/kg was 10.4 (CI: 1.76-61.67, Z-score: 2.58, P = .01), and combined TV <5 mL/kg and TF < 25% is 17.6 (CI: 1.19-259.61, Z-score: 2.09, P = .04). CONCLUSIONS Our preliminary study suggests that ultrasound measurements of diaphragm thickening fraction during spontaneous breaths in mechanically ventilated pediatric patients may be a useful addition in predicting weaning readiness.
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Affiliation(s)
- Ami J Shah
- Hassenfeld Children's Center, New York University Langone - Pediatric Critical Care, New York, NY, USA
- Children's National Hospital - Pediatric Critical Care, Washington, DC, USA
| | - Kitman Wai
- Children's National Hospital - Pediatric Critical Care, Washington, DC, USA
| | - Matthew P Sharron
- Children's National Hospital - Pediatric Critical Care, Washington, DC, USA
| | - Marisa Mize
- Children's National Hospital - Pediatric Critical Care, Washington, DC, USA
| | - Joanna Cohen
- Children's National Hospital - Pediatric Emergency Department, Washington, DC, USA
| | - Sonali Basu
- Children's National Hospital - Pediatric Critical Care, Washington, DC, USA
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Ultrasound Versus Computed Tomography for Diaphragmatic Thickness and Skeletal Muscle Index during Mechanical Ventilation. Diagnostics (Basel) 2022; 12:diagnostics12112890. [PMID: 36428947 PMCID: PMC9689333 DOI: 10.3390/diagnostics12112890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/08/2022] [Accepted: 11/16/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Diaphragmatic alterations occurring during mechanical ventilation (MV) can be monitored using ultrasound (US). The performance of computed tomography (CT) to evaluate diaphragmatic thickness is limited. Further, the association between muscle mass and outcome is increasingly recognized. However, no data are available on its correlation with diaphragmatic thickness. We aimed to determine correlation and agreement of diaphragmatic thickness between CT and US; and its association with muscle mass and MV parameters. Methods: Prospective observational study. US measurements of the diaphragmatic thickness were collected in patients undergoing MV within 12 h before or after performing a CT scan of the thorax and/or upper abdomen. Data on skeletal muscle index (SMI), baseline, and ventilatory data were recorded and correlated with US and CT measures of diaphragmatic thickness. Agreement was explored between US and CT data. Results: Twenty-nine patients were enrolled and the diaphragm measured by CT resulted overall thicker than US-based measurement of the right hemidiaphragm. The US thickness showed the strongest correlation with the left posterior pillar at CT (r = 0.49, p = 0.008). The duration of the controlled MV was negatively correlated with US thickness (r = -0.45, p = 0.017), the thickness of the right anterior pillar (r = -0.41, p = 0.029), and splenic dome by CT (r = -0.43, p = 0.023). SMI was positively correlated with US diaphragmatic thickness (r = 0.50, p = 0.007) and inversely correlated with the duration of MV before enrollment (r = -0.426, p = 0.027). Conclusions: CT scan of the left posterior pillar can estimate diaphragmatic thickness and is moderately correlated with US measurements. Both techniques show that diaphragm thickness decreases with MV duration. The diaphragmatic thickness by US showed a good correlation with SMI.
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Haaksma ME, Smit JM, Kramer R, Heldeweg MLA, Veldhuis LI, Lieveld A, Pikerie D, Mousa A, Girbes AR, Heunks L, Tuinman PR. Evolution of Respiratory Muscles Thickness in Mechanically Ventilated Patients With COVID-19. Respir Care 2022; 67:1369-1376. [PMID: 35882471 PMCID: PMC9993963 DOI: 10.4187/respcare.10063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Given the long ventilation times of patients with COVID-19 that can cause atrophy and contractile weakness of respiratory muscle fibers, assessment of changes at the bedside would be interesting. As such, the aim of this study was to determine the evolution of respiratory muscle thickness assessed by ultrasound. METHODS Adult (> 18 y old) patients admitted to the ICU who tested positive for SARS-CoV-2 and were ventilated for < 24 h were consecutively included. The first ultrasound examination (diaphragm, rectus abdominis, and lateral abdominal wall muscles) was performed within 24 h of intubation and regarded as baseline measurement. After that, each following day an additional examination was performed, for a maximum of 8 examinations per subject. RESULTS In total, 30 subjects were included, of which 11 showed ≥ 10% decrease in diaphragm thickness from baseline; 10 showed < 10% change, and 9 showed ≥ 10% increase from baseline. Symptom duration before intubation was highest in the decrease group (12 [11-14] d, P = .03). Total time ventilated within the first week was lowest in the increase group (156 [129-172] h, P = .03). Average initial diaphragm thickness was 1.4 (1.1-1.6) mm and did not differ from final average thickness (1.3 [1.1-1.5] mm, P = .54). The rectus abdominis did not show statistically significant changes, whereas lateral abdominal wall thickness decreased from 14 [10-16] mm at baseline to 11 [9-13] mm on the last day of mechanical ventilation (P = .08). Mixed-effect linear regression demonstrated an association of atrophy and neuromuscular-blocking agent (NMBA) use (P = .01). CONCLUSIONS In ventilated subjects with COVID-19, overall no change in diaphragm thickness was observed. Subjects with decreased or unchanged thickness had a longer ventilation time than those with increased thickness. NMBA use was associated with decreased thickness. Rectus muscle thickness did not change over time, whereas lateral abdominal muscle thickness decreased but this change was not statistically significant.
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Affiliation(s)
- Mark E Haaksma
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; Amsterdam Leiden Intensive Care Focused Echography Amsterdam, the Netherlands; and Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, the Netherlands.
| | - Jasper M Smit
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; Amsterdam Leiden Intensive Care Focused Echography Amsterdam, the Netherlands; and Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, the Netherlands
| | - Ruben Kramer
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Micah LA Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; Amsterdam Leiden Intensive Care Focused Echography Amsterdam, the Netherlands; and Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, the Netherlands
| | - Lars I Veldhuis
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Arthur Lieveld
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Dagnery Pikerie
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Amne Mousa
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; Amsterdam Leiden Intensive Care Focused Echography Amsterdam, the Netherlands; and Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, the Netherlands
| | - Armand Rj Girbes
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; and Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, the Netherlands
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; and Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, the Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; Amsterdam Leiden Intensive Care Focused Echography Amsterdam, the Netherlands; and Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, the Netherlands
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ABUDUREZAKE ABULAITI, MORITA TERUMASA, MORI TAKUYA, AMANO ATSUSHI. Validity of Diaphragm Volume Measurements Using Three-Dimensional Computed Tomography. JUNTENDO IJI ZASSHI = JUNTENDO MEDICAL JOURNAL 2022; 68:481-490. [PMID: 39081579 PMCID: PMC11284297 DOI: 10.14789/jmj.jmj22-0006-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/16/2022] [Indexed: 08/02/2024]
Abstract
Objectives The aim of this study was to measure the diaphragm volume using three-dimensional computed tomography (3D-CT) and verify its validity. Design This was a retrospective study of existing samples. Methods Participants comprised five male patients, aged 65-70 years, who underwent preoperative chest CT (with a slice thickness of 0.5 mm) before coronary artery bypass surgery. The diaphragm was selectively extracted using a workstation to reconstruct a stereoscopic image, and the total muscle volume was measured. To confirm the accuracy and reproducibility of diaphragm muscle volume measurements on CT, all cases were measured three times by two observers, and intraclass correlation coefficients (ICCs) and interobserver correlations were determined. Results Observers #1 and #2 reported an average diaphragm volume of 256.7±33 cm3 and 259.3±36 cm3, respectively. The ICC analyses yielded Cronbach's alphas of 0.992 and 0.981 from both observers, and the interobserver correlation was 0.991. The ICC of a single measurement and the average measurement was 0.984 (95% confidence interval: 0.998-0.884) and 0.992 (95% confidence interval: 0.999-0.939), respectively. Conclusions To our knowledge, this study is the first to standardize the method for measuring the total diaphragm volume and examine the reproducibility and validity of the new method. The diaphragm could be selectively extracted and reconstructed. Measurement of the total diaphragm muscle volume using a workstation to reconstruct a stereoscopic image is feasible and highly reproducible. This technique can be reliably employed to evaluate diaphragm volume, thickness, and morphology.
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Affiliation(s)
- ABULAITI ABUDUREZAKE
- Corresponding author: Abulaiti Abudurezake, Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan, TEL: +81-3-5802-1080 FAX: +81-3-3815-5228 E-mail:
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Pearson SD, Lin J, Stutz MR, Lecompte-Osorio P, Pohlman AS, Wolfe KS, Hall JB, Kress JP, Patel BK. Immediate Effect of Mechanical Ventilation Mode and Sedative Infusion on Measured Diaphragm Thickness. Ann Am Thorac Soc 2022; 19:1543-1550. [PMID: 35404772 PMCID: PMC9447392 DOI: 10.1513/annalsats.202111-1280oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 04/11/2022] [Indexed: 11/20/2022] Open
Abstract
Rationale: In patients who are mechanically ventilated, diaphragm thinning on ultrasound is thought to correlate with diaphragm atrophy and has been associated with prolonged intubation. Factors other than atrophy, however, may cause changes in diaphragm thickness, which may confound studies examining changes in diaphragm thickness over time. Objectives: To determine if changes in the mode of mechanical ventilation or an interruption of sedatives have immediate effects on diaphragm thickness measurements in adult patients in the intensive care unit who are mechanically ventilated. Methods: Adult patients receiving invasive mechanical ventilation for less than 48 hours were included. Diaphragm thickness was measured at end-expiration and peak inspiration using ultrasound while patients were receiving both volume assist-control and pressure-support modes in a randomized crossover fashion. In patients receiving sedatives, additional measurements were taken after an interruption of sedatives. Measurements were compared between modes and on assist-control before and after an interruption of sedatives. Results: Of 85 patients enrolled, 66 had measurements on assist-control and spontaneous modes, and 40 had measurements before and after an interruption of sedatives. End-expiratory diaphragm thickness increased by a median of 0.08 mm after an interruption of sedatives (95% confidence interval [CI], 0.002 mm to 0.164 mm; P = 0.017), corresponding to a median increase of 6.5%. No difference was seen when comparing measurements taken on volume assist-control and pressure support (median difference, 0 mm; 95% CI, -0.07 mm to 0.08 mm; P = 0.98). Conclusions: End-expiratory diaphragm thickness increased by 6.5% after an interruption of sedatives. The effect of sedatives on measured diaphragm thickness should be considered in future studies examining changes in diaphragm thickness over time. Clinical trial registered with Clinicaltrials.gov (NCT04319939).
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Affiliation(s)
- Steven D. Pearson
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Julie Lin
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | - Matthew R. Stutz
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | | | - Anne S. Pohlman
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Krysta S. Wolfe
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jesse B. Hall
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - John P. Kress
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Bhakti K. Patel
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
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Haaksma ME, van Tienhoven AJ, Smit JM, Heldeweg MLA, Lissenberg-Witte BI, Wennen M, Jonkman A, Girbes ARJ, Heunks L, Tuinman PR. Anatomical Variation in Diaphragm Thickness Assessed with Ultrasound in Healthy Volunteers. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:1833-1839. [PMID: 35691733 DOI: 10.1016/j.ultrasmedbio.2022.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/21/2022] [Accepted: 05/09/2022] [Indexed: 06/15/2023]
Abstract
Ultrasonography of the diaphragm in the zone of apposition has become increasingly popular to evaluate muscle thickness and thickening fraction. However, measurements in this anatomical location are frequently hindered by factors that constrain physical accessibility or that alter diaphragm position. Therefore, other anatomical positions at the chest wall for transducer placement are used, but the variability in diaphragm thickness across the dome has not been systematically studied. The aim of this study was to evaluate anatomical variation of diaphragm thickness in 46 healthy volunteers on three ventrodorsal lines and two craniocaudal positions on these three lines. The intraclass correlation coefficient (ICC) for diaphragm thickness in the craniocaudal direction on the mid-axillary line was significantly higher than those on the posterior axillary and midclavicular lines, suggesting it had the lowest variability (ICCmidaxillary = .89, 95% confidence interval [CI]: 0.83-0.93, ICCposterior axillary = 0.74, 95% CI: 0.62-0.85, ICCmidclavicular = 0.62, 95% CI: 0.43-0.47, p < 0.05). Average diaphragm thickness was comparable on the posterior axillary and midaxillary lines and substantially larger on the midclavicular line (1.24 mm [1.06-1.47], 1.27 mm [1.10-1.42] and 2.32 [1.97-2.70], p < 0.01). We conclude that the normal diaphragm has a large variability in thickness, especially in the ventrodorsal direction. Variability in craniocaudal position is the lowest at the midaxillary line, which therefore appears to be the preferred site for diaphragm thickness measurement.
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Affiliation(s)
- Mark E Haaksma
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands; Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Arne J van Tienhoven
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Jasper M Smit
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands; Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Micah L A Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands; Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Birgit I Lissenberg-Witte
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Myrte Wennen
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Annemijn Jonkman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands; Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands; Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
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Dot I, Pérez-Terán P, Francés A, Díaz Y, Vilà-Vilardell C, Salazar-Degracia A, Chalela R, Barreiro E, Rodriguez-Fuster A, Masclans JR, Marin-Corral J. Association between histological diaphragm atrophy and ultrasound diaphragm expiratory thickness in ventilated patients. J Intensive Care 2022; 10:40. [PMID: 35986366 PMCID: PMC9392308 DOI: 10.1186/s40560-022-00632-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/03/2022] [Indexed: 11/24/2022] Open
Abstract
Background Diaphragm fiber atrophy has been evidenced after short periods of mechanical ventilation (MV) and related to critical illness-associated diaphragm weakness. Atrophy is described as a decrease in diaphragm fiber cross-sectional area (CSA) in human diaphragm biopsy, but human samples are still difficult to obtain in clinics. In recent years, ultrasound has become a useful tool in intensive care to evaluate diaphragm anatomy. The present study aimed to evaluate the ability of diaphragm expiratory thickness (Tdi) measured by ultrasound to predict diaphragm atrophy, defined by a decrease in diaphragm fiber CSA obtained through diaphragm biopsy (the gold standard technique) in ventilated patients. Methods Diaphragm biopsies and diaphragm ultrasound were performed in ventilated donors and in control subjects. Demographic variables, comorbidities, severity on admission, treatment, laboratory test results and evolution variables were evaluated. Immunohistochemical analysis to determine CSA and ultrasound measurements of Tdi at end-expiration were performed, and median values of the control group were used as thresholds to determine agreement between them in further analysis. Sensitivity, specificity, and positive and negative predictive values of an ultrasound Tdi cutoff for detecting histologic atrophy were calculated. Agreement between two ultrasound observers was also assessed. Results Thirty-five ventilated organ donors and 5 ventilated controls were included, without differences in basic characteristics. CSA and Tdi were lower in donors than in controls. All donors presented lower CSA, but only 74% lower Tdi regarding control group thresholds. The cut-off value for lower diaphragm expiratory thickness (Tdi < 1.7 mm) presented a sensitivity of 73%, a specificity of 67%, a positive predictive value of 96% and a negative predictive value of 17% for determining the presence of diaphragm atrophy (CSA < 2851 μm2). Conclusions Diaphragm atrophy and thickness reduction is associated to MV. While a lower Tdi in diaphragm ultrasound is a good tool for diagnosing atrophy, normal or increased Tdi cannot rule atrophy out showing that both parameters should not be considered as synonymous.
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Patel N, Chong K, Baydur A. Methods and Applications in Respiratory Physiology: Respiratory Mechanics, Drive and Muscle Function in Neuromuscular and Chest Wall Disorders. Front Physiol 2022; 13:838414. [PMID: 35774289 PMCID: PMC9237333 DOI: 10.3389/fphys.2022.838414] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
Individuals with neuromuscular and chest wall disorders experience respiratory muscle weakness, reduced lung volume and increases in respiratory elastance and resistance which lead to increase in work of breathing, impaired gas exchange and respiratory pump failure. Recently developed methods to assess respiratory muscle weakness, mechanics and movement supplement traditionally employed spirometry and methods to evaluate gas exchange. These include recording postural change in vital capacity, respiratory pressures (mouth and sniff), electromyography and ultrasound evaluation of diaphragmatic thickness and excursions. In this review, we highlight key aspects of the pathophysiology of these conditions as they impact the patient and describe measures to evaluate respiratory dysfunction. We discuss potential areas of physiologic investigation in the evaluation of respiratory aspects of these disorders.
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Zhang YG, Chen Y, Zhang YL, Yi J. Comparison of the effects of neostigmine and sugammadex on postoperative residual curarization and postoperative pulmonary complications by means of diaphragm and lung ultrasonography: a study protocol for prospective double-blind randomized controlled trial. Trials 2022; 23:376. [PMID: 35526047 PMCID: PMC9077960 DOI: 10.1186/s13063-022-06328-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/23/2022] [Indexed: 11/24/2022] Open
Abstract
Background Postoperative residual curarization (PORC) may be a potential risk factor of postoperative pulmonary complications (PPCs), and both of them will lead to adverse consequences on surgical patient recovery. The train-of-four ratio (TOFr) which is detected by acceleromyography of the adductor pollicis is thought as the gold standard for the measurement of PORC. However, diaphragm function recovery may differ from that of the peripheral muscles. Recent studies suggested that diaphragm ultrasonography may be useful to reveal the diaphragm function recovery, and similarly, lung ultrasound was reported for the assessment of PPCs in recent years as well. Sugammadex reversal of neuromuscular blockade is rapid and complete, and there appear to be fewer postoperative complications than with neostigmine. This study aims to compare the effects of neostigmine and sugammadex, on PORC and PPCs employing diaphragm and lung ultrasonography, respectively. Methods/design In this prospective, double-blind, randomized controlled trial, patients of the American Society of Anesthesiologists Physical Status I–III, aged over 60, will be enrolled. They will be scheduled to undergo arthroplasty under general anesthesia. All patients will be allocated randomly into two groups, group NEO (neostigmine) and group SUG (sugammadex), using these two drugs for reversing rocuronium. The primary outcome of the study is the incidence of PPCs in the NEO and SUG groups. The secondary outcomes are the evaluation of diaphragm ultrasonography and lung ultrasound, performed by an independent sonographer before anesthesia, and at 10 min and 30 min after extubation in the post-anesthesia care unit, respectively. Discussion Elimination of PORC is a priority at the emergence of anesthesia, and it may be associated with reducing postoperative complications like PPCs. Sugammadex was reported to be superior to reverse neuromuscular blockade than neostigmine. Theoretically, complete recovery of neuromuscular function should be indicated by TOFr > 0.9. However, the diaphragm function recovery may not be the same matter, which probably harms pulmonary function. The hypothesis will be proposed that sugammadex is more beneficial than neostigmine to reduce the incidence of PPCs and strongly favorable for the recovery of diaphragm function in our study setting. Trial registration ClinicalTrials.gov NCT05040490. Registered on 3 September 2021 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06328-3.
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Affiliation(s)
- Yu-Guan Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Ying Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Yue-Lun Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Jie Yi
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China.
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43
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Zhang D, Hao W, Li X, Han P, Niu Q. Aldh1a1 and Scl25a30 in diaphragmatic dysfunction. Exp Biol Med (Maywood) 2022; 247:1013-1029. [PMID: 35410502 DOI: 10.1177/15353702221085201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
New methods to prevent ventilator-induced diaphragmatic dysfunction (VIDD) are urgently needed, and the cellular basis of VIDD is poorly understood. This study evaluated whether transvenous phrenic nerve stimulation (PNS) could prevent VIDD in rabbits undergoing mechanical ventilation (MV) and explored whether oxidative stress-related genes might be candidate molecular markers for VIDD. Twenty-four adult male New Zealand white rabbits were allocated to control, MV, and PNS groups (n = 8 in each group). Rabbits in the MV and PNS groups underwent MV for 24 h. Intermittent bilateral transvenous PNS was performed in rabbits in the PNS group. Transdiaphragmatic pressure was recorded using balloon catheters. The diameters and cross-sectional areas (CSAs) of types I and II diaphragmatic fibers were measured using immunohistochemistry (IHC) techniques. Genes associated with VIDD were identified by RNA sequencing (RNA-seq), differentially expressed gene (DEG) analysis, and weighted gene co-expression network analysis (WGCNA). Reverse transcription polymerase chain reaction (RT-PCR), Western blotting, and IHC analyses were carried out to verify the transcriptome profile. Pdi60Hz, Pdi80Hz, and Pdi100Hz were significantly higher in the PNS group than in the MV group at 12 and 24 h (P < 0.05 at both time points). The diameters and CSAs of types I (slow-twitch) and II (fast-twitch) fibers were significantly larger in the PNS group than in the MV group (P < 0.05). RNA-seq, RT-PCR, Western blotting, and IHC experiments identified two candidate genes associated with VIDD: Aldh1a1 and Scl25a30. The MV group had significantly higher mRNA and protein expressions of Aldh1a1/ALDH1A1 and significantly lower mRNA and protein expressions of Scl25a30/SCL25A30 than the control or PNS groups (P < 0.05). We have identified two candidate genes involved in the prevention of VIDD by transvenous PNS. These two key genes may provide a theoretical basis for targeted therapy against VIDD.
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Affiliation(s)
- Dong Zhang
- Department of Critical Care Medicine, Heping Hospital Affiliated to Changzhi Medical College, Changzhi 046000, China
| | - Wenyan Hao
- Department of Biomedical Engineering, Changzhi Medical College, Changzhi 046000, China
| | - Xujiong Li
- Department of Physiology, Changzhi Medical College, Changzhi 046000, China
| | - Pengyong Han
- The Central Lab, Changzhi Medical College, Changzhi 046000, China
| | - Qi Niu
- Department of Critical Care Medicine, Heping Hospital Affiliated to Changzhi Medical College, Changzhi 046000, China
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Kharasch SJ, Selame L, Dumas H, Shokoohi H, Liteplo A, Kharasch E, Kharasch V. Point-of-care respiratory muscle ultrasound in a child with medical complexity. Pediatr Pulmonol 2022; 57:333-336. [PMID: 34714975 DOI: 10.1002/ppul.25743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Sigmund J Kharasch
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lauren Selame
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Helene Dumas
- Department of Pediatrics, Franciscan Hospital for Children, Boston, Massachusetts, USA
| | - Hamid Shokoohi
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew Liteplo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eleanor Kharasch
- Department of Pediatrics, Franciscan Hospital for Children, Boston, Massachusetts, USA.,Cummings School of Veterinary Medicine, Tufts University, Grafton, Massachusetts, USA
| | - Virginia Kharasch
- Department of Pediatrics, Franciscan Hospital for Children, Boston, Massachusetts, USA
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Satkunendrarajah K, Karadimas SK, Fehlings MG. Spinal cord injury and degenerative cervical myelopathy. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:241-257. [PMID: 36031307 DOI: 10.1016/b978-0-323-91532-8.00006-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Spinal cord injury (SCI) often results in impaired respiratory function. Paresis or paralysis of inspiratory and expiratory muscles can lead to respiratory dysfunction depending on the level and severity of the injury, which can affect the management and care of SCI patients. Respiratory dysfunction after SCI is more severe in high cervical injuries, with vital capacity (VC) being an essential indicator of overall respiratory health. Respiratory complications include hypoventilation, a reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Respiratory management includes mechanical ventilation and tracheostomy in high cervical SCI, while noninvasive ventilation is more common in patients with lower cervical and thoracic injuries. Mechanical ventilation can negatively impact the function of the diaphragm and weaning should start as soon as possible. Patients can sometimes be weaned from mechanical ventilation with assistance of electrical stimulation of the phrenic nerve or the diaphragm. Respiratory muscle training regimens may also improve patients' inspiratory function following SCI. Despite the critical advances in preventing, diagnosing, and treating respiratory complications, they continue to significantly affect persons living with SCI. Additional studies of interventions to reduce respiratory complications are likely to further decrease the morbidity and mortality associated with these injuries.
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Affiliation(s)
- Kajana Satkunendrarajah
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States; Department of Neuroscience, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, United States; Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Spyridon K Karadimas
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Genetics and Development, Krembil Brain Institute, University Health Network, Toronto, ON, Canada.
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Spadaro S, Dalla Corte F, Scaramuzzo G, Grasso S, Cinnella G, Rosta V, Chiavieri V, Alvisi V, Di Mussi R, Volta CA, Bellini T, Trentini A. Circulating Skeletal Troponin During Weaning From Mechanical Ventilation and Their Association to Diaphragmatic Function: A Pilot Study. Front Med (Lausanne) 2021; 8:770408. [PMID: 35004739 PMCID: PMC8727747 DOI: 10.3389/fmed.2021.770408] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/22/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Patients with acute respiratory failure (ARF) may need mechanical ventilation (MV), which can lead to diaphragmatic dysfunction and muscle wasting, thus making difficult the weaning from the ventilator. Currently, there are no biomarkers specific for respiratory muscle and their function can only be assessed trough ultrasound or other invasive methods. Previously, the fast and slow isoform of the skeletal troponin I (fsTnI and ssTnI, respectively) have shown to be specific markers of muscle damage in healthy volunteers. We aimed therefore at describing the trend of skeletal troponin in mixed population of ICU patients undergoing weaning from mechanical ventilation and compared the value of fsTnI and ssTnI with diaphragmatic ultrasound derived parameters. Methods: In this prospective observational study we enrolled consecutive patients recovering from acute hypoxemic respiratory failure (AHRF) within 24 h from the start of weaning. Every day an arterial blood sample was collected to measure fsTnI, ssTnI, and global markers of muscle damage, such as ALT, AST, and CPK. Moreover, thickening fraction (TF) and diaphragmatic displacement (DE) were assessed by diaphragmatic ultrasound. The trend of fsTnI and ssTnI was evaluated during the first 3 days of weaning. Results: We enrolled 62 consecutive patients in the study, with a mean age of 67 ± 13 years and 43 of them (69%) were male. We did not find significant variations in the ssTnI trend (p = 0.623), but fsTnI significantly decreased over time by 30% from Day 1 to Day 2 and by 20% from Day 2 to Day 3 (p < 0.05). There was a significant interaction effect between baseline ssTnI and DE [F(2) = 4.396, p = 0.015], with high basal levels of ssTnI being associated to a higher decrease in DE. On the contrary, the high basal levels of fsTnI at day 1 were characterized by significant higher DE at each time point. Conclusions: Skeletal muscle proteins have a distinctive pattern of variation during weaning from mechanical ventilation. At day 1, a high basal value of ssTnI were associated to a higher decrease over time of diaphragmatic function while high values of fsTnI were associated to a higher displacement at each time point.
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Affiliation(s)
- Savino Spadaro
- Department of Translational Medicine, Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
- *Correspondence: Savino Spadaro
| | - Francesca Dalla Corte
- Department of Translational Medicine, Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Gaetano Scaramuzzo
- Department of Translational Medicine, Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Salvatore Grasso
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Gilda Cinnella
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Valentina Rosta
- Section of Medical Biochemistry, Molecular Biology and Genetics, Department of Biomedical and Specialist Surgical Sciences, University of Ferrara, Ferrara, Italy
| | - Valentina Chiavieri
- Department of Translational Medicine, Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Valentina Alvisi
- Department of Translational Medicine, Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Rosa Di Mussi
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Carlo Alberto Volta
- Department of Translational Medicine, Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Tiziana Bellini
- Section of Medical Biochemistry, Molecular Biology and Genetics, Department of Biomedical and Specialist Surgical Sciences, University of Ferrara, Ferrara, Italy
| | - Alessandro Trentini
- Section of Medical Biochemistry, Molecular Biology and Genetics, Department of Biomedical and Specialist Surgical Sciences, University of Ferrara, Ferrara, Italy
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Valverde Montoro D, García Soler P, Hernández Yuste A, Camacho Alonso JM. Ultrasound assessment of ventilator-induced diaphragmatic dysfunction in mechanically ventilated pediatric patients. Paediatr Respir Rev 2021; 40:58-64. [PMID: 33744085 DOI: 10.1016/j.prrv.2020.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Ultrasonography has recently emerged as a promising technique that can rapidly estimate diaphragm function, especially during the weaning period. The aims of this study were to describe the evolution of diaphragmatic morphology and functional measurements by ultrasound in ventilated children. MATERIAL AND METHODS This was a prospective, observational, single-center study. All the children admitted to our Pediatric Intensive Care Unit requiring mechanical ventilation for more than 48 h were included. Diaphragmatic thickness and the thickening fraction were assessed by ultrasound. RESULTS From June to December 2018, 47 patients (median age 3 months; interquartile range, 1-17) underwent 164 ultrasonographic evaluations. The median duration of mechanical ventilation was 168 h (interquartile range, 96-196). At the initial measurement, the thickness at end-inspiration was 2.2 mm (interquartile range, 1.8-2.5) and the thickness at end-expiration was 1.8 mm (interquartile range, 1.5-2.0) with a median decrease in thickness of -14% (interquartile range, -33% to -3%) and a -2% daily atrophy rate (interquartile range, -4.2% to 0%). Diaphragmatic atrophy was observed in 30/47 cases. Children who had been exposed to neuromuscular blockade infusion (n = 31) had a significantly lower mean thickness [-22% (interquartile range, -34% to -13%) vs. -6% (interquartile range, -12% to 0%); p = 0.009] and increased daily atrophy rate [-2.2% (interquartile range, -4.6 to 0%) vs. -1.4% (interquartile range, -2.6 to 0%); p = 0.049] compared to unexposed children. The decrease in thickness was significantly less in children ventilated for at least 12 hours with pressure support before extubation compared with those with shorter periods of spontaneous respiratory effort [-9.5% (interquartile range, -21 to 0%) vs. -26% (interquartile range, -37 to -12%); p = 0.011]. CONCLUSIONS Point-of-care diaphragmatic ultrasound can detect diaphragmatic atrophy in mechanically ventilated children. Diaphragmatic atrophy was strongly associated with the use of mechanical ventilation and neuromuscular blockade. Diaphragmatic thickness also tended to decrease less in the pre-extubation stage with pressure support. We found no correlation between progressive diaphragm thinning, extubation failure, or an increased need for non-invasive ventilation post extubation.
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Nascimento TS, de Queiroz RS, Ramos ACC, Martinez BP, Da Silva E Silva CM, Gomes-Neto M. Ultrasound Protocols to Assess Skeletal and Diaphragmatic Muscle in People Who Are Critically Ill: A Systematic Review. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:3041-3067. [PMID: 34417065 DOI: 10.1016/j.ultrasmedbio.2021.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 06/13/2023]
Abstract
This study aims to review published studies that use protocols and ultrasound measurements to evaluate skeletal and diaphragmatic muscles in patients who are critically ill. We searched for references on databases through September 2020 and included in our systematic review studies that used muscular ultrasound to assess skeletal or diaphragm muscles in patients who are critically ill. Seventy-six studies were included, 32 (1720 patients) using skeletal-muscle ultrasound and 44 (2946 patients) using diaphragmatic-muscle ultrasound, with a total of 4666 patients. The population is predominantly adult men. As for designs, most studies (n = 62) were cohort studies. B-mode B was dominant in the evaluations. Medium-to-high frequency bands were used in the analysis of peripheral muscles and medium-to-low frequency bands for diaphragmatic muscles. Evaluation of the echogenicity, muscle thickness and pennation angle of the muscle was also reported. These variables are important in the composition of the diagnosis of muscle loss. Studies demonstrate great variability in their protocols, and sparse description of the important variables that can directly interfere with the quality and validity of these measures. Therefore, a document is needed that standardizes these parameters for ultrasound assessment in patients who are critically ill.
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Affiliation(s)
- Taís Silva Nascimento
- Physiotherapy Research Group, Federal University of Bahia, Brazil; Program in Medicine and Health of the Faculty of Medicine, Federal University of Bahia, Salvador, Brazil.
| | - Rodrigo Santos de Queiroz
- Department of Health 1, State University of Southwest Bahia, Brazil; Program in Medicine and Health of the Faculty of Medicine, Federal University of Bahia, Salvador, Brazil
| | | | - Bruno Prata Martinez
- Physiotherapy Research Group, Federal University of Bahia, Brazil; Physical Therapy Department, Federal University of Bahia, Brazil; Program in Medicine and Health of the Faculty of Medicine, Federal University of Bahia, Salvador, Brazil
| | | | - Mansueto Gomes-Neto
- Physical Therapy Department, Federal University of Bahia, Brazil; Program in Medicine and Health of the Faculty of Medicine, Federal University of Bahia, Salvador, Brazil
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Aarab Y, Flatres A, Garnier F, Capdevila M, Raynaud F, Lacampagne A, Chapeau D, Klouche K, Etienne P, Jaber S, Molinari N, Gamon L, Matecki S, Jung B. Shear Wave Elastography, A New Tool for Diaphragmatic Qualitative Assessment. A Translational Study. Am J Respir Crit Care Med 2021; 204:797-806. [PMID: 34255974 DOI: 10.1164/rccm.202011-4086oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Prolonged mechanical ventilation (MV) is often associated either with a decrease (known atrophy) or an increase (supposed injury) in diaphragmatic thickness. Shear wave elastography is a non-invasive technique that measures shear modulus, a surrogate of tissue stiffness and mechanical properties. OBJECTIVES To describe changes in shear modulus (SM) during the ICU stay and the relationship with alterations in muscle thickness. To perform a comprehensive ultrasound-based characterization of histological and force production changes occurring in the diaphragm. METHODS Translational study using critically ill patients and mechanically ventilated piglets. Serial ultrasound examination of the diaphragm collecting thickness and SM was performed in both patients and piglets. Transdiaphragmatic pressure and diaphragmatic biopsies were collected in piglets. MEASUREMENTS AND MAIN RESULTS We enrolled 102 patients, 88 of whom were invasively mechanically ventilated. At baseline, SM was 14.3+/-4.3 kPa and diaphragm end-expiratory thickness was 2.0+/-0.5 mm. Decrease or increase by more than 10% from baseline was reported in 86% of the patients for thickness and in 92% of the patients for shear modulus. An increase in diaphragmatic thickness during the stay was associated with a decrease in SM (β=-9.34±4.41; p=0.03) after multivariable analysis. In the piglet sample, a decrease in SM over 3 days of MV was associated with loss of force production, slow and fast fiber atrophy and increased lipid droplets accumulation. CONCLUSIONS Increases in diaphragm thickness during critical illness is associated with decreased tissue stiffness as demonstrated by shear wave ultrasound elastography, consistent with the development of muscle injury and weakness.
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Affiliation(s)
| | | | - Fanny Garnier
- Centre Hospitalier Regional Universitaire de Montpellier, 26905, Montpellier, France
| | - Mathieu Capdevila
- Montpellier University and Montpellier Teaching Hospital,, Saint Eloi Anesthesiology and Critical Care Medicine, Montpellier University and Montpellier Teaching Hospital, Montpellier, France , Montpellier, France.,Montpellier Universite d'Excellence, 539031, PhyMedExp, Montpellier, France
| | | | - Alain Lacampagne
- PhyMedExp, Montpellier University, INSERM, CNRS, Montpellier, France
| | - David Chapeau
- Lapeyronie University Hospital, Intensive Care Unit, Montpellier, France
| | - Kada Klouche
- Lapeyronie University Hospital, Intensive Care Unit, Montpellier, France
| | - Pascal Etienne
- Laboratoire Charles Coulomb, 131799, Montpellier, France
| | - Samir Jaber
- University hospital. CHU de MONTPELLIER HOPITAL SAINT ELOI, Intensive Care Unit and transplantation-Departement of Anesthesiology DAR B, Montpellier Cedex 5, France
| | - Nicolas Molinari
- CHU Montpellier - Hôpital la Colombière, DIM, Montpellier, France
| | - Lucie Gamon
- Montpellier University and Montpellier Teaching Hospital,, Saint Eloi Anesthesiology and Critical Care Medicine, Montpellier University and Montpellier Teaching Hospital, Montpellier, France
| | - Stefan Matecki
- Universite de Montpellier, 27037, 4. Pediatric Functional Exploration Unit, University Hospital of Montpellier, Montpellier, France
| | - Boris Jung
- Centre Hospitalier Regional Universitaire de Montpellier, 26905, medical ICU, Montpellier, France;
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Nakanishi N, Takashima T, Oto J. Muscle atrophy in critically ill patients : a review of its cause, evaluation, and prevention. THE JOURNAL OF MEDICAL INVESTIGATION 2021; 67:1-10. [PMID: 32378591 DOI: 10.2152/jmi.67.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Critically ill patients exhibit prominent muscle atrophy, which occurs rapidly after ICU admission and leads to poor clinical outcomes. The extent of atrophy differs among muscles as follows: upper limb: 0.7%-2.4% per day, lower limb: 1.2%-3.0% per day, and diaphragm 1.1%-10.9% per day. This atrophy is caused by numerous risk factors such as inflammation, immobilization, nutrition, hyperglycemia, medication, and mechanical ventilation. Muscle atrophy should be monitored noninvasively by ultrasound at the bedside. Ultrasound can assess muscle mass in most patients, although physical assessment is limited to almost half of all critically ill patients due to impaired consciousness. Important strategies to prevent muscle atrophy are physical therapy and electrical muscular stimulation. Electrical muscular stimulation is especially effective for patients with limited physical therapy. Regarding diaphragm atrophy, mechanical ventilation should be adjusted to maintain spontaneous breathing and titrate inspiratory pressure. However, the sufficient timing and amount of nutritional intervention remain unclear. Further investigation is necessary to prevent muscle atrophy and improve long-term outcomes. J. Med. Invest. 67 : 1-10, February, 2020.
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Affiliation(s)
- Nobuto Nakanishi
- Emergency and Critical Care Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima 770-8503, Japan
| | - Takuya Takashima
- Emergency and Critical Care Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima 770-8503, Japan
| | - Jun Oto
- Emergency and Disaster Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima 770-8503, Japan
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